COMMUNICATION AND PATIENT SAFETY

Successful encounters with patients begin with a professional, respectful, and compassionate approach.

• Positive communications should begin by addressing the patient using proper titles such as Ms., Mrs., or Mr.; the inappropriate use of terms of endearment is a common patient complaint.
• Health-care providers (HCPs) should always introduce and identify themselves to the patient before explaining the upcoming laboratory or diagnostic study. An example is to say, “Good morning. My name is Lilli and I will be your nurse today.”
• Always conclude the conversation by asking if there are any questions before leaving the room.
• If you have a concern about a patient’s level of understanding with the conversation, ask the individual to repeat what you have just explained so you can confirm that there are no issues.

Teach the patient what to expect.

Statement of the purpose of the study.

• The level of detail provided to patients about the test purpose depends on numerous factors and should be individualized appropriately in each setting. After the introduction, explain in easily understandable age-, culture-, and gender-appropriate terms about the study that is to be performed. Ask the patient to discuss their health concerns to give you a sense of how to begin the discussion. General information to communicate should include study type (e.g., blood, x-ray, magnetic resonance imaging [MRI], urine, etc.) and the purpose or common use of the test (e.g., to assist in the diagnosis of diabetes, to assess the function of the kidneys, to identify the presence of findings that would either confirm a condition or confirm the absence of a health problem).

Description of the procedure and associated safety practices.

• Describe the procedure, what part of the body will be evaluated, whether or not the procedure is invasive, where the procedure will take place, and who will participate in performing the study.
• It is a good idea to explain to the patient that gloves will be worn by the health-care providers (HCPs) throughout the procedure. Many institutions require hand washing at the beginning and end of each specimen collection encounter and between each patient. This explanation should help the patient understand that the use of gloves is standard practice established for everyone’s safety and protection.
• Inquire about and document the patient’s known allergies.
• Explain that it is essential the patient be positively and properly identified at every encounter before care, treatment, or services are provided. Patients may become concerned that they are asked to repeat their personal identification information. They may misinterpret this safety practice as incompetence, lack of communication, or lack of interest.
• Typically, two patient-specific identifiers are used and may vary between inpatient and outpatient areas. Chosen identifiers may include full name, medical record number, or date of birth.

Addressing the need for informed consent.

• Some procedures may require informed, written consent as described in the facility’s policy and procedure manual. What does informed (written) consent mean? Who is responsible for obtaining a consent?
• The exact definition and implementation of informed consent vary among states and individual health-care facilities in the United States. Best practices suggest a team approach. However, the concept of informed consent is generally based on the underlying moral and legal premises of patient autonomy found in a health-care facility’s Bill of Patient’s Rights and specific clinical policies. The U.S. Department of Health and Human Services describes informed consent to mean that if treatment is needed, the requesting HCP must provide that individual with the information needed to make the decision to agree with or decline the specified treatment plan. While many common patient-HCP interactions involve an implied voluntary consent, some specific procedures require informed, written consent. The list of tests and treatments requiring consent varies among facilities and may change with advances in clinical practice and technology. Generally, informed written consent is required for invasive procedures, tests, or treatments with significant risks, benefits, and alternatives. Once the requesting HCP has provided information to the patient, the informed patient’s written consent must then be obtained and documented by the person designated in the facility’s policy. The consent must be signed after the patient has been informed and before the procedure or administration of any medications that would affect the patient's ability to make an important decision. There are a few legal exceptions to obtaining an informed (written) consent. Most commonly, they occur when there is a medical emergency that would result in death if not addressed immediately or in the case of mental incompetence in which an individual is unable to give or refuse consent and there is no surrogate (legal guardian or health-care proxy). Patient assault and patient battery are the legal terms put forth regarding the failure to obtain consent (as required by a facility’s policies) before performing a test or procedure or allowing a deviation from the consented test or procedure to occur (unless an additional consent is appropriately obtained).
• Make sure a written and informed consent has been signed for the requested study and properly documented prior to the procedure and prior to administering any medications and according to your facility’s requirements (Figure A–1).

Figure A–1 Obtaining an informed and signed consent.

Description of the sensations, including discomfort and pain, that may be experienced during specimen collection or a diagnostic procedure.

• Address concerns about pain related to the procedure, and suggest breathing or visualization techniques to promote relaxation.
• For pediatric patients, a doll may be used to “show” the procedure.
• Explain that where appropriate, sedative or anesthetizing agents may be used to assist in allaying anxiety the patient may experience related to anticipation of pain associated with the procedure.
• Sedation and anesthesia are used to facilitate the completion of selected studies. Conscious or monitored sedation uses medication to promote relaxation and minimize pain while at the same time allowing the patient to remain conscious enough to communicate with the HCP. This approach is used to prevent pain and injury during a procedure.
• General anesthesia is medication given to cause a type of coma in which the patient is without consciousness or awareness and is protected from experiencing any pain associated with the procedure. However, with this type of sedation, the patient is also left without any protective reflexes.

General instruction regarding pretesting preparations.

• Explain pretesting diet, fluid, medication, or activity instructions and why strict adherence to the instructions is required to obtain accurate results.
• Fasting means no caloric intake for 8 or more hours.
• Failure to follow dietary, fluid, medication, activity, or other restrictions before the blood test or diagnostic procedure may cause the procedure to be canceled or repeated.

The practice of an overnight fast before a laboratory test is a general recommendation.

• Reference ranges are often based on fasting populations to provide some level of standardization for comparison.
• Some test results are dramatically affected by foods, and fasting is a pretest requirement.
• The presence of lipids in the blood also may interfere with the test method; fasting eliminates this potential source of error, especially if the patient already has elevated lipid levels.
• The laboratory should always be consulted if there is a question whether fasting is a requirement or a recommendation.

The practice of an overnight fast before a diagnostic test is a general recommendation.

• Dietary restrictions are usually related either to avoiding complications (e.g., aspiration), as with the use of anesthesia or other medications known to cause nausea and vomiting, or to avoiding factors that may alter the results of the study (e.g., undigested food that obscures visualization of the area of interest).

Specific patient preparation instructions and specimen collection techniques vary by site, study required, and level of invasiveness. The following guidelines should be implemented for all studies.

• Orders should be completed accurately and submitted per laboratory or diagnostic procedural policy.
• Positive patient identification extends to all specimens collected from the patient. Specimens should always be labeled, after collection per CLSI standards, with two patient-specific identifiers (e.g., the patient’s name, date of birth, medical record number, or some other unique identifier), date collected, time collected, initials of the person collecting the sample, and laterality, if applicable (e.g., biopsies).

Recognition of anxiety related to test results.

• Provide a compassionate, reassuring environment.
• Encourage the patient to ask questions and verbalize concerns.
• Offer contact information for nationally recognized Web sites.

Results notification.

• Timely notification of a critical finding for laboratory or diagnostic studies is a role expectation of the professional nurse.
• Follow the facility’s procedure for reporting and documenting critical findings.

Pediatric considerations for a laboratory or diagnostic study.

• Preparing children depends on the age of the child. Encourage parents to be truthful about unpleasant sensations (cramping, pressure, pinching, etc.) the child may experience during the procedure and to use words that they know their child will understand. Toddlers and preschool-age children have a very short attention span, so the best time to talk about the test is right before the procedure. The child should be assured that they will be allowed to bring a favorite comfort item into the examination room, and if appropriate, that a parent will be with the child during the procedure.
• Explain to parents and caregivers that special equipment (balloon-tip catheters to assist with retention of barium during a barium enema, foam wedges used to hold a limb in place during a nuclear scan, etc.) may be needed to assist with a successful study.
• Postprocedural recovery interventions, such as achieving adequate hydration, require close attention. The parents or caregivers must receive education to help them address specific needs and to be watchful for indications of a developing problem because pediatric patients cannot do so for themselves.

Older adult considerations for a laboratory or diagnostic study.

• Older adult patients present with a variety of concerns when undergoing diagnostic procedures. Level of cooperation and fall risk may be complicated by underlying problems such as visual and hearing impairment, joint and muscle stiffness, physical weakness, mental confusion, and the effects of medications.
• A fall injury can be avoided by providing assistance getting on and off the examination table and getting on and off the toilet before and at the end of the examination.
• Older adult patients are often chronically dehydrated; anticipating the effects of hypovolemia and orthostasis can also help prevent falls.
• Older patients who are small in size compared to other adults also may receive a higher radiation dose than necessary if settings are not adjusted for their size.
• Special equipment (balloon-tip catheters to assist with retention of barium during a barium enema, foam wedges used to hold a limb in place during a nuclear scan, etc.) may be needed to assist with a successful study.
• Postprocedural recovery interventions, such as achieving adequate hydration, require close attention.
• Many older patients wish to maintain their independence. Their caregivers must receive education to help them address specific needs and to be watchful for indications of a developing problem; the limits of an older adult patient’s physical and intellectual abilities may be an obstacle to independently carrying out the proper postprocedural care.