Threaten Patient Safety Research Articles

Future agenda for emergency medical service in Korea: from silos to systems

The primary role of the emergency medical services system in Korea is to provide quality urgent medical care. However, this system is regularly called on to perform additional roles such as responding to public health emergencies like the MERS-CoV outbreak and contributing to suicide prevention and chronic disease management. Despite substantial increases in the quantity and utilization of emergency medical services such as ambulances, the quality of the services has not improved significantly in the past decade. Overcrowding in Korea's emergency departments has threatened patient safety, particularly in large hospitals, with delayed care for patients and an increased risk of hospital-spread infections. To address these problems, the capacity of regional emergency medical centers must be augmented and an even distribution of quality achieved nationwide. The establishment of an organized delivery system for emergency medical services will improve pre-hospital transportation of patients and patient transfers between hospitals. Moreover, the introduction of an incentive system and the active involvement of emergency medical specialists in quality assessment programs are required to encourage providers to improve the quality of emergency medical services. Lastly, to meet the growing demands for emergency medical services, a system of integration between emergency medical care and general medical care should be instituted.

Technicians are seeking powers that would threaten patient safety, claims PDA

Technicians are seeking powers that would threaten patient safety, claims PDA

Association of Sleep Characteristics with Medication Errors for Shift Work Nurses in Intensive Care Units*

Purpose: Shift work disrupts the synchronization between the human biological clock and the environment. Sleep disturbances are common for shift work nurses, and may threaten patient safety. This study was done to investigate the sleep characteristics and medication errors (ME) of intensive care unit (ICU) nurses who work shifts, and ascertain if there is an association between these factors. Methods: Data were collected using a self-report questionnaire from 126 ICU nurses on three shifts. Collected data included their sleep characteristics including sleep patterns and sleep disturbances, and ME for the past 2 weeks. Results: There were significant differences in sleep duration and sleep latency according to shift. Day shift nurses had the shortest sleep duration, and their sleep latency was the longest (about 49 minutes) compared to nurses on evening and night shifts; 54% reported sleep disturbances, 16% experienced ME, and among these nurses 50% were on the night shift. Logistic regression analysis revealed significant associations between nurses` sleep duration and ME (adjusted OR 0.52 [95% CI 0.32-0.85]). Conclusions: The results confirmed that shift work nurses in the ICUs experience sleep disturbance, and that less sleep is associated with ME.

Innovation of communication technology to improve information transfer during handover

Background: Efficient information transfer during handover is a key part of high quality care. Handover represents a transition point in the patient pathway where there is susceptibility to communication failure, this can threaten patient safety. Existing communication technologies are sub-optimal and require innovation in line with modern technology in use by clinicians and the general public. The advent of web-based instant messaging and rapid app development in the mHealth arena provide better functionality for the consumer compared to old methods of communication. The healthcare industry should take advantage of this innovative time. This study aims to provide evidence-based, user-informed recommendations for the development of an application-based communication system (ABCS) tailored for use during patient handover. Methods: Phase 1: A systematic literature review aiming to identify best evidence exploring interventions in the handover process. Phase 2: Ethnographic, inter-professional observations to uncover issues surrounding patient handover in UK hospitals. Phase 3: Focus group sessions with International Digital Health and Care Congress, The King’s Fund, London, September 10-12 2014. International Journal of Integrated Care – Volume 14, 01 November – URN:NBN:NL:UI:10-1-116494– http://www.ijic.org/ 26 surgeons and nurses from 3 UK hospitals were conducted to uncover desirable features to include in an ABCS for surgical handover. Both homogenous and heterogeneous sessions were organised, to ensure methodological rigour. Focus groups were recorded and transcribed verbatim before being subjected to independent thematic analysis. Results: Phase 1: Analysis of 19 articles revealed that existing evidence for handover interventions is sparse with no exploration of patient outcome. All handover interventions were based on protocols or guidance templates; there were no app-based interventions and limited use of technology. Observation sessions lasted 3 hours and were conducted on 6 separate occasions on surgical wards by a mixture of designers and clinicians. Observation was performed during both night and day sessions to ensure comprehensive data capture. They revealed issues surrounding absence of junior staff co-ordination, confusion over patient locations, lack of feedback for nurses when contacting doctors and a lack of communication between teams outside normal working hours. The focus group sessions revealed great enthusiasm for communication technology innovation. Participants identified 6 themes detailing user perceptions of current communication technology and attitudes to smartphone technology. They felt that the pager device was outdated. The participants produced, via consensus agreement, 9 key recommendations to include in development of an ABCS: 1. Communication triage by senior staff 2. Communication triage based on clinical urgency 3. Feedback to establish a closed communication loop 4. Structured data input to include demographics and patient location 5. A team conversation function 6. Robust security systems to maintain confidentiality 7. Mobile devices for doctors and ward-based devices for nurses

A model of disruptive surgeon behavior in the perioperative environment.

Surgeons are the physicians with the highest rates of documented disruptive behavior. We hypothesized that a unified conceptual model of disruptive surgeon behavior could be developed based on specific individual and system factors in the perioperative environment. Semi-structured interviews were conducted with 19 operating room staff of diverse occupations at a single institution. Interviews were analyzed using grounded theory methods. Participants described episodes of disruptive surgeon behavior, personality traits of perpetrators, environmental conditions of power, and situations when disruptive behavior was demonstrated. Verbal hostility and throwing or hitting objects were the most commonly described disruptive behaviors. Participants indicated that surgical training attracts and creates individuals with particular personality traits, including a sense of shame. Interviewees stated this behavior is tolerated because surgeons have unchecked power, have strong money-making capabilities for the institution, and tend to direct disruptive behavior toward the least powerful employees. The most frequent situational stressors were when something went wrong during an operation and working with unfamiliar team members. Each factor group (ie, situational stressors, cultural conditions, and personality factors) was viewed as being necessary, but none of them alone were sufficient to catalyze disruptive behavior events. Disruptive physician behavior has strong implications for the work environment and patient safety. This model can be used by hospitals to better conceptualize conditions that facilitate disruptive surgeon behavior and to establish programs to mitigate conduct that threatens patient safety and employee satisfaction.

Handoff Communication and Electronic Health Records

When transferring patient care responsibilities across the healthcare continuum, clinicians strive to communicate safely and effectively, but communication failures exist that threaten patient safety. Although researchers are making great strides in understanding and solving intraservice handoff problems, inter-service transition communication remains underexplored. Further, electronic health records (EHRs) figure prominently in healthcare delivery, but less is known about how EHRs contribute to inter-service handoffs. This descriptive, qualitative study uses Sensemaking Theory to explore EHR-facilitated, inter-service handoffs occurring between emergency medicine and internal/hospitalist medicine physicians. The researchers conducted six focus groups with 16 attending physicians and medical residents at a major Midwestern academic hospital. Findings suggest clinicians hold varied expectations for information content and relational communication/style. Their expectations contribute to making sense of uncertain handoff situations and communication best practices. Participants generally perceive EHRs as tools that, when used appropriately, can enhance handoffs and patient care continuity. Ideas for practical applications are offered based on study results.

Towards a framework for untangling complexity: The interprofessional decision‐making model for the complex patient

Decision making for the complex patient is challenging for doctors because of increased complexity, such as multiple co‐morbidities and interprofessionality for which evidence‐based literature and guidelines are currently lacking. The consequent uncertainty causes vagueness, threatening patient safety and the quality of care. This article is motivated by the design science paradigm and describes the interprofessional decision‐making model for the complex patient, namely, INDECO along with an example instantiation. Drawing on our experience in an intensive care unit of a tertiary hospital in Israel, the bi‐dimensional view of this model includes the medical‐ and the interprofessional perspective. Retrospective assessment of 3 case studies of complex patients is used for assessing the usefulness of INDECO in decision making. The study reported here draws support from relevant literature, including the information science, information systems, and the medical domains. The findings resonate with emerging research developments focusing on healthcare decision making.

Inconsistent regulation threatens patient safety, researchers warn

A lack of consistency in the way doctors are regulated across Europe could have “significant implications” for the safety of patients, researchers have warned. A study published in the International Journal for Quality in Health Care assessed how medical regulators managed professional issues involving quality and patient safety in the UK, Austria, Belgium, Estonia, Germany, Hungary, the Netherlands, Slovenia, and Spain. …

Safety of medical therapy in patients with chronic kidney disease and end-stage renal disease

Maintaining patient safety is a necessary step to improve healthcare delivery. Patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) have an increased frequency of adverse safety events largely because of medication errors. CKD and ESRD have several features which threaten patient safety. Reduced glomerular filtration rate affects the clearance of many medications and is also associated with several comorbidities such as diabetes, cardiovascular disease, metabolic bone disease, and anemia. These comorbidities of CKD often increase the complexity of treatment regimens. Patients with ESRD, requiring dialysis or transplantation, have an even greater potential for adverse safety events because of the reliance on renal replacement modalities and the frequent requirements of polypharmacy and potential drug-drug interactions. There is an important need to develop strategies to provide inpatient and outpatient management plans to limit the risk of adverse medication errors across a wide range of educational and socioeconomic backgrounds, and a critical need to develop a uniform set of standards for evaluating patient safety in CKD and ESRD as well as appropriate descriptions of the prototypical safety profiles of patients who have CKD, a kidney transplant, or who are on dialysis.

ABSTRACT 796

Background and aims: Latent safety threats may contribute to medical errors and have a significant impact on patient safety. We describe identified latent patient safety threats during in-situ-simulations in German pediatric hospitals. Aims: Development of a patient safety checklist for pediatric emergencies in children´s hospitals to avoid common deficits in patient care. Methods: The feedback evaluations of 19 in-situ courses (each 2.5 days) at non-affiliated children´s hospitals in Germany were analyzed after informed consent relating to the incidence of latent safety threats by observing equipment (e.g. special equipment for airway- or circulation management, emergency backpack or case, storage,..), logistics (e.g. emergency call, emergency room), medication and both technical and non-technical skills. Results: 431 latent patient safety threats were detected. All 431 safety threats were summarized in 66 different categories. Most mentioned logistic items were things like equipment storage in different places and oversupply of emergency equipment. In the medication category, mistakes in the attenuation of epinephrine and storage of similar sounding medications side by side were most prevalent. Regarding the technical skills, impart knowledge of the current guidelines and lacks in the use of technical equipment (i.o.-access, defibrillator) were observed. Conclusions: The identified latent safety threats in pediatric emergency care show a high rate of previously unidentified items. According to these results a patient safety checklist must be established to avoid these common deficits in the patient care. We developed a safety checklist regarding our results combined with already published data and guidelines. This checklist will be tested for practicability by using in in-situ-trainings and by evaluation with a Delphi procedure.

Statewide Surveillance of Carbapenem-Resistant Enterobacteriaceae in Michigan

Carbapenem-resistant Enterobacteriaceae (CRE) are clinically challenging, threaten patient safety, and represent an emerging public health issue. CRE reporting is not mandated in Michigan. The Michigan Department of Community Health-led CRE Surveillance and Prevention Initiative enrolled 21 facilities (17 acute care and 4 long-term acute care facilities) across the state. Baseline data collection began September 1, 2012, and ended February 28, 2013 (duration, 6 months). Enrolled facilities voluntarily reported cases of Klebsiella pneumoniae and Escherichia coli according to the surveillance algorithm. Patient demographic characteristics, laboratory testing, microbiology, clinical, and antimicrobial information were captured via standardized data collection forms. Facilities reported admissions and patient-days each month. One-hundred two cases over 957,220 patient-days were reported, resulting in a crude incidence rate of 1.07 cases per 10,000 patient-days. Eighty-nine case patients had test results positive for K. pneumoniae, whereas 13 had results positive for E. coli. CRE case patients had a mean age of 63 years, and 51% were male. Urine cultures (61%) were the most frequently reported specimen source. Thirty-five percent of cases were hospital onset; sixty-five percent were community onset (CO), although 75% of CO case patients reported healthcare exposure within the previous 90 days. Cardiovascular disease, renal failure, and diabetes mellitus were the most frequently reported comorbid conditions. Common ris k factors included surgery within the previous 90 days, recent infection or colonization with a multidrug-resistant organism, and recent exposures to antimicrobials, especially third- or fourth-generation cephalosporins. CRE are found throughout Michigan healthcare facilities. Implementing a regional, coordinated surveillance and prevention initiative may prevent CRE from becoming hyperendemic in Michigan.

Burden of endemic healthcare-associated infection in Africa

Healthcare-associated infection (HAI) occurs in every healthcare facility in every country and affects hundreds of millions of patients annually worldwide, including in developing countries. Although HAIs are the most frequent adverse event threatening patient safety, reliable estimates of the global burden are hampered by the lack of data, particularly in Africa. For example, a recent systematic review of HAI in Africa retrieved only a small number of articles (19) reporting studies conducted in 10 African countries. The overall prevalence of HAI ranged from 2.5% to 14.8%, up to twice as high as the average European prevalence (7.1%) reported by the European Centre for Disease Prevention and Control. However, some important aspects need to be considered. African settings with the capacity to conduct surveillance studies and publish data may have greater resources to implement infection prevention and control programmes than those who do not collect and publish data. Thus, the real burden of HAI is likely to be even greater in settings with weaker infrastructures and fewer resources. Most included studies (13/19) were conducted in university/teaching hospitals that usually function as referral hospitals and accept patients requiring more complex care. For these reasons, such hospitals generally report higher infection rates. No national studies were identified and only one multicentre study in two hospitals was retrieved, which makes the difficulties of conducting coordinated and regular HAI surveillance in Africa all too clear. In 2005, WHO launched the First Global Patient Safety Challenge “Clean Care is Safer Care” to create a global momentum and commitment to reduce HAI, raise awareness of the importance of HAI as a major patient safety issue, build country commitment to tackle the problem, and develop tools and guidance documents. Within the development process, the WHO guidelines on hand hygiene in health care and the multimodal hand hygiene improvement strategy underwent a pilot test phase to assess their feasibility and adaptability to the local context and resources available. The results of the African test site in Bamako, Mali, clearly demonstrated that multimodal hand hygiene promotion is feasible and effective in low-income settings. To reinforce the importance of patient safety, a technical paper detailing 12 key action areas, including the reduction of HAIs, was prepared by the WHO African Regional Office in collaboration with WHO Patient Safety and endorsed by all 46 African Member States. In response to this political commitment to improve patient safety, African Partnerships for Patient Safety was launched with the particularl aim of reducing HAI across the region.Given the lack of data available, efforts to reduce HAI in Africa should begin with surveillance activities aimed towards estimating the associated burden of morbidity and mortality.

Capsule Commentary on Singh et al., A Qualitative Evaluation of Geographical Localization of Hospitalists: How Unintended Consequences May Impact Quality

This study qualitatively assessed the impact of co-locating hospitalists and nurses on patient care.1 Using focus groups, nurse and provider participants reported a positive impact, mediated by proximity and improved communication. Focus groups also developed a conceptual model demonstrating how geographic localization could affect several key elements of patient care. This paper also elucidated four potential unintended consequences of co-localization: 1) increased communication interruptions, which could threaten patient safety; 2) rather than a constant flow of new patients from multiple teams, co-located teams had admission flow problems, with patients often arriving in boluses, which tended to overwhelm nursing resources; 3) the teams were generalist teams and this could potentially disrupt wards with nursing units that are specialized; and 4) there was the potential for perverse incentives to increase length of stay, as found in previous work.2 This study has several limitations. The sample size was small, including only two hospitalist teams and one nursing unit, and many constituents of medical teams, such as pharmacists, case managers and social workers, were not included. Moreover, despite the primary interest in the impact on patient care, there were no patients’ voices reflected in the results. Despite these limitations, the model looks reasonable and fits well with what we imagine would happen if this co-localization were deployed. For the next step, researchers might want to further refine their conceptual model by more qualitative research with a larger, more diverse sample including staff other than doctors and nurses, incorporating the patient’s perspective. In addition, further quantitative investigations on the impact of co-localization are also needed. Previous research of co-localization of hospitalist with nursing teams found increased satisfaction and no impact on readmission rates,2,3 but no improvement in agreement between nurses and providers on the care plan2 and possibly increased length of stay.3 Research on uninvestigated domains of quality such as patient safety is also a future task. Finally, ward teams provide functions other than patient care; for example, education. The potential impact of co-localization on aspects of the medical enterprise other than direct patient care should be evaluated.

Fragmentation of Care Threatens Patient Safety in Peripheral Vascular Catheter Management in Acute Care– A Qualitative Study

BackgroundThe use of peripheral vascular catheters (PVCs) is an extremely common and necessary clinical intervention, but inappropriate PVC care poses a major patient safety risk in terms of infection. Quality improvement initiatives have been proposed to reduce the likelihood of adverse events, but a lack of understanding about factors that influence behaviours of healthcare professionals limits the efficacy of such interventions. We undertook qualitative interviews with clinical staff from a large group of hospitals in order to understand influences on PVC care behaviors and subsequent patient safety.MethodsTen doctors, ten clinical pharmacists, 18 nurses and one midwife at a National Health Service hospital group in London (United Kingdom) were interviewed between December 2010 and July 2011 using qualitative methods. Responses were analysed using a thematic framework.ResultsFour key themes emerged: 1) Fragmentation of management and care, demonstrated with a lack of general overview and insufficient knowledge about expected standards of care or responsibility of different professionals; 2) feelings of resentment and frustration as a result of tensions in the workplace, due to the ambiguity about professional responsibilities; 3) disregard for existing hospital policy due to perceptions of flaws in the evidence used to support it; and 4) low-risk perception for the impact of PVC use on patient safety.ConclusionFragmentation of practice resulted in ill-defined responsibilities and interdisciplinary resentment, which coupled with a generally low perception of risk of catheter use, appeared to result in lack of maintaining policy PVC standards which could reduced patient safety. Resolution of these issues through clearly defining handover practice, teaching interdisciplinary duties and increasing awareness of PVC risks could result in preventing thousands of BSIs and other PVC-related infections annually.

A Model of Disruptive Surgeon Behavior in the Perioperative Environment

Background Surgeons are the physicians with the highest rates of documented disruptive behavior. We hypothesized that a unified conceptual model of disruptive surgeon behavior could be developed based on specific individual and system factors in the perioperative environment. Study Design Semi-structured interviews were conducted with 19 operating room staff of diverse occupations at a single institution. Interviews were analyzed using grounded theory methods. Results Participants described episodes of disruptive surgeon behavior, personality traits of perpetrators, environmental conditions of power, and situations when disruptive behavior was demonstrated. Verbal hostility and throwing or hitting objects were the most commonly described disruptive behaviors. Participants indicated that surgical training attracts and creates individuals with particular personality traits, including a sense of shame. Interviewees stated this behavior is tolerated because surgeons have unchecked power, have strong money-making capabilities for the institution, and tend to direct disruptive behavior toward the least powerful employees. The most frequent situational stressors were when something went wrong during an operation and working with unfamiliar team members. Each factor group (ie, situational stressors, cultural conditions, and personality factors) was viewed as being necessary, but none of them alone were sufficient to catalyze disruptive behavior events. Conclusions Disruptive physician behavior has strong implications for the work environment and patient safety. This model can be used by hospitals to better conceptualize conditions that facilitate disruptive surgeon behavior and to establish programs to mitigate conduct that threatens patient safety and employee satisfaction.

Exploring perinatal shift‐to‐shift handover communication and process: an observational study

Loss of situation awareness (SA) by health professionals during handover is a major threat to patient safety in perinatal care. SA refers to knowing what is going on around. Adequate handover communication and process may support situation assessment, a precursor of SA. This study describes current practices and opinions of perinatal handover to identify potential improvements. Structured direct observations of shift-to-shift patient handovers (n = 70) in an academic perinatal setting were used to measure handover communication (presence and order of levels of SA: current situation, background, assessment and recommendation) and process (duration, interruptions/distractions, eye contact, active inquiry and reading information back). Afterwards, receivers' opinions of handover communication (n = 51) were measured by means of a questionnaire. All levels of SA were present in 7% of handovers, the current situation in 86%, the background in 99%, an assessment in 24% and a recommendation in 46%. In 77% of handovers the background was mentioned first, followed by the current situation. Forty-four per cent of handovers took 2 minutes or more per patient. In 52% distractions occurred, in 43% there was no active inquiry, in 32% no eye contact and in 97% information was not read back. The overall mean of the receivers' opinions of handover communication was 4.1 (standard deviation ± 0.7; scale 1-5, where 5 is excellent). Perinatal handovers are currently at risk for inadequate situation assessment because of variability and limitations in handover communication and process. However, receivers' opinions of handover communication were very positive, indicating a lack of awareness of patient safety threats during handover. Therefore, the staff's awareness of current limitations should be raised, for example through video reflection or simulation training.

Patients and learners: time for a re-evaluation of our goals in bringing them together

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Challenging Authority During a Life-Threatening Crisis

Background Effective operating theatre (OT) communication is important for team function and patient safety. Status asymmetry between team members may contribute to communication breakdown and threaten patient safety. We investigated how hierarchy in the OT team influences an anaesthesia trainee's ability to challenge an unethical decision by a consultant anaesthetist in a simulated crisis scenario. Methods We prospectively randomized 49 postgraduate year (PGY) 2–5 anaesthesia trainees at two academic hospitals to participate in a videotaped simulated crisis scenario with a simulated OT team practicing either a hierarchical team structure (Group H) or a non-hierarchical team structure (Group NH). The scenario allowed trainees several opportunities to challenge their consultant anaesthetist when administering blood to a Jehovah's Witness. Three independent, blinded raters scored the performances using a modified advocacy–inquiry score (AIS). The primary outcome was the comparison of the best-response AIS between Groups H vs NH. Secondary outcomes included the comparison of best AIS by PGY and the percentage in each group that checked and administered blood. Results The AIS did not differ between the groups (P=0.832) but significantly improved from PGY2 to PGY5 (P=0.026). The rates of checking blood (92% vs 76%, P=0.082) and administering blood (62% vs 57%, P=0.721) were high in both groups but not significantly different between the groups. Conclusions This study did not show a significant effect of OT team hierarchical structure on trainee's ability to challenge authority; however, the results are concerning. The challenges were suboptimal in quality and there was an alarming high rate of blood checking and administration in both groups. This may reflect lack of training in appropriately and effectively challenging authority within the formal curriculum with implications for patient safety.

An RFID solution for enhancing inpatient medication safety with real-time verifiable grouping-proof

PurposeThe occurrence of a medication error can threaten patient safety. The medication administration process is complex and cumbersome, and nursing staffs are prone to error when they are tired. Proper Information Technology (IT) can assist the nurse in correct medication administration. MethodWe review a recent proposal [15] regarding a leading-edge solution to enhance inpatient medication safety by using RFID technology. The proof mechanism is the kernel concept in their design and worth studying to develop a well-designed grouping-proof scheme. Other RFID grouping-proof protocols [17–21] could be similarly applied in administering physician orders. We improve on the weaknesses of previous works and develop a reading-order independent RFID grouping-proof scheme in this paper. ResultIn our scheme, tags are queried and verified under the direct control of the authorized reader without connecting to the back-end database server. Immediate verification in our design makes this application more portable and efficient and critical security issues have been analyzed by the threat model. ConclusionOur scheme is suitable for the safe drug administration scenario and the drug package scenario in a hospital environment to enhance inpatient medication safety. It automatically checks for correct drug unit-dose and appropriate inpatient treatments.

Communication and Collaboration: Creating a Culture of Teamwork Through the Use of TeamSTEPPS Strategies

Professional Issues Poster Presentation Purpose for the Program To improve patient safety and satisfaction by implementing an evidence‐based system to enhance communication and teamwork skills among healthcare professionals. Proposed Change TeamSTEPPS is an innovative program that works to solidify collaboration among the healthcare team to achieve the best outcomes for patients. A multidisciplinary group committed to changing the culture of the department attended the TeamSTEPPS master training course. The team identified communication as a recurring problem that threatened patient safety and satisfaction. The team then developed the department‐wide as an intervention to improve communication. Implementation, Outcomes, and Evaluation The women's services department consists of high‐risk labor and delivery (L&D), well‐baby nursery, level II and level III neonatology units, mother–baby couplet unit, and perinatal special care unit. Direct patient care providers from the departmental units attended the TeamSTEPPS fundamentals 4‐hour interactive workshop. This workshop provided hands‐on learning experience of the TeamSTEPPS philosophy as well as an opportunity to practice the TeamSTEPPS behaviors. At 8 a.m. and 8 p.m. daily, the obstetric (OB) faculty member on duty conducts the interdisciplinary department‐wide snapshot. The snapshot is a scripted report that begins with the OB faculty giving L&D staff the big picture report. Next, the L&D team lead nurse reports on inductions, surgeries, expected patients, antepartum unit census and concerns, OB triage status, and patients waiting for beds and staffing. The OR nurse discusses concerns about scheduled cases and the mother–baby team lead nurse reports census, discharges, and concerns. The nurse–midwife and family medicine resident report on admitted patients and bring to light any concerns they may have. Next, staff from the anesthesia department discuss the OR cases, epidurals infusing, problem epidurals, and anticipated high‐risk cases. The staff from the neonatology department then has an opportunity to discuss any concerns. To close the snapshot, the OB faculty clearly states, any team member sees anything unsafe or not in the best interests of our patients, we expect you to speak up. If you are unable to get a timely or effective response, call me, OB faculty, Dr. _______. Improved communication has been evidenced by expediting safe mother–baby discharges during periods of increased census, improved operating room productivity, timely and effective neonatology consultations, and accessibility and accountability of the OB faculty member on duty. Implications for Nursing Practice Effective collaboration and communication are essential elements of professional nursing. The department‐wide snapshot encourages nurses to be actively involved in the multidisciplinary healthcare team and make valuable, evidence‐based contributions to patient safety and satisfaction.