Policies & Procedures Document Title:

Originating Entity : quality performance

Effective Communication
and patient safety
Date Originated: 22/11 /2010 Document No.: POL-ACC-001-3
Approved By: Chairman Of Quality Date Revised: 25/12 /2010
Performance And Patient Safety
Date of Approval: 22/12 /2010 Rev. No.: 00
Approved By: Chairman Of Accreditation Next Revision Date : 25/12 /2012
Steering Committee
Page 1 of 11
Date of Approval: 25/12 /2010

I. Purpose:
1. To establish a professional communication and link between professional healthcare givers,
departments involved in patient care, between patient and families.
2. To establish accuracy and timeliness of communicating critical test results and values.

II. Policy:
1. General Principles:
1.1 The official languages used in 48 Model Hospital while at work either in oral or
writing are: English and Arabic.
1.2 Harassing (BAD) words are not allowed to be used in any of the communication;
and using the same languages addressed to the patient’s family is not allowed either.
1.3 Observe confidentiality when communicating restricted information i.e. patient’s
data and health condition.
2. Communication protocols for healthcare providers (HCP):
2.1 Use only internationally accepted and internally approved abbreviations in
writing orders or documenting patient care.
2.1.1 “Do not use” abbreviations are not to be used in any documented
communications instead, write the complete word. (Refer to Appendix “1” for
List of Do Not Use Abbreviation.)
2.1.2 Any unclear orders using abbreviations must be clarified from the
physician giving the order.
2.2 Accurate and timely documentation of care and services provided to patients.
2.3 Verbal or telephone order shall be:
2.3.1 Documented(Form VTORB001, refer to Attachment “A”) to be signed by
the HCP receiving the verbal or telephone order and by the ordering physician
within the same shift or 24 hours maximum.
2.3.2 read-back by the receiving nurse or HCP and to be confirmed by the
ordering physician before it is carried out.
2.3.3 Exception when is read-back not necessary:
2.3.3.1 Physician to physician consultation such as when a detail of
consultation is given by a Radiologist to primary physician.
2.3.3.2 Dialogue between professionals i.e. physician to physician of the
same specialty or peers.
2.3.3.3 In certain situations such as code blue or in the OR when it may
not be feasible to do a formal read-back but repeat-back shall be used.

Confidential Information
Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures Document Title:
Originating Entity : quality performance
Effective Communication
and patient safety
Date Originated: 22/11 /2010 Document No.: POL-ACC-001-3
Approved By: Chairman Of Quality Date Revised: 25/12 /2010
Performance And Patient Safety
Date of Approval: 22/12 /2010 Rev. No.: 00
Approved By: Chairman Of Accreditation Next Revision Date : 25/12 /2012
Steering Committee
Page 2 of 11
Date of Approval: 25/12 /2010

2.4 Report-back of critical results such as telephoning the patient care unit to report
results of STAT tests. The result shall be written down by the receiving HCP; then
read-back the result; and wait for the confirmation by the one giving the result.
2.5 Hand-over Communication (Shift Endorsement) shall be conducted by health
care providers before and after each shift to endorse what has been done and not done
(to be continued) during the shift.
 Shift duties, the endorsement shall be conducted between incoming and outgoing
shifts within 30 minutes before the close of outgoing shifts.
 Collaborative (multidisciplinary) rounds shall be used effectively to improve
communication and hand-over of important information relating to the patient’s
care; and to involve the patient by asking questions about the condition.
 Hand-over communication must be done between different patient care units in
the course of a patient transfer to endorse the patient’s condition, treatments, and
documentations and involving the patient.
2.6 Involve the patient and family in communication as they are the only
constant keeper of important aspects of care and are in a position to play a critical
role in ensuring continuity of care.
2.7 Training on effective hand-over communication.

III. Scope of Policy:

This policy applies to all 48 model hospital staff who provides patient care services .

IV. Responsibilities:
It is the Responsibility of the involved staff "(nurse, medical, records, physicians ) and QPS
Committee shall be responsible to monitor the communication activities within the scope of
this policies and procedures.

V. Definitions:
1. Communication is the process of transferring messages from a sender to a receiver.
Message may contain information, ideas, emotions, skills or direction. The methods of
transferring messages can be verbal or non-verbal (in the form of: sign language, writing,
pictorial, graphic, symbols and/or figures).
2. “Do not use” list A written catalog of abbreviation and symbols that are not to be used
throughout an organization—whether handwritten or entered as free text into a computer
—due to their potentially confusing nature.
3. Verbal or telephone order is an order given by a physician to a nurse or healthcare
provider orally or by telephone call. It is not a written order hence, it is called “verbal”

Confidential Information
Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures Document Title:
Originating Entity : quality performance
Effective Communication
and patient safety
Date Originated: 22/11 /2010 Document No.: POL-ACC-001-3
Approved By: Chairman Of Quality Date Revised: 25/12 /2010
Performance And Patient Safety
Date of Approval: 22/12 /2010 Rev. No.: 00
Approved By: Chairman Of Accreditation Next Revision Date : 25/12 /2012
Steering Committee
Page 3 of 11
Date of Approval: 25/12 /2010

4. Read-back is the process of taking verbal or telephone order from a physician with the
nurse or HCP writing down the order and then read it back to the ordering physician.
The person taking the verbal or telephone order will not close the communication until
the physician confirms that such order is correct.
5. Repeat-back is taking verbal order and repeating it back to the physician without
writing it. The physician shall confirm the repeat-back is correct. This is acceptable only
in emergency situation such as during Code Blue and in situation where the patient is in
Operating Room and that read back is impossible.
6. Critical test results are diagnostic test results of abnormal values that if not reported on
time, management will be delayed that can result to patient’s severe harm.
7. Hands-off communication relates to the process of passing patient-specific information
(patient’s condition, recent changes in condition, ongoing treatments or procedures) from
one caregiver to another, from one team of caregivers to the next, or from caregivers to
the patient and family for the purpose of ensuring patient care continuity and safety.
8. SBARQ is a situational briefing techniques which stands for
S=Situation B=Background A=Assessment R=Recommendation Q=Question
It can provide a standard communication framework for patient care hand-over.
9. Health literacy is defined as the capacity of individuals to obtain, process and
understand the basic health information and services needed to make appropriate health
decisions.
10. Teach-back is a technique used by caregivers to ensure that the patient has understood
the information provided.
11. HCP means Health Care Provider.

VI. Procedure:
1: Handling Verbal or Telephone Order:
1.1: Form (VTORB001) for verbal or telephone order or reporting of STAT test results shall be
available for use (Refer to Attachment “A”).
1.2: The health care service provider when receiving verbal or telephone order shall:
1.2.1: write first the order on proper verbal/telephone order’s form to document it.
1.2.2: Then read-back the written order to the ordering physician and wait for the doctor
to confirm.
1.2.3: Let the ordering physician confirm that the order is understood correctly.
1.2.4: Sign the filled form.
1.2.5: Let the doctor to sign the verbal or telephone order within 24 hours and/or during
the same shift, if feasible.
2: Report-back of critical results such as telephoning the patient care unit to report results of

Confidential Information
Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures Document Title:
Originating Entity : quality performance
Effective Communication
and patient safety
Date Originated: 22/11 /2010 Document No.: POL-ACC-001-3
Approved By: Chairman Of Quality Date Revised: 25/12 /2010
Performance And Patient Safety
Date of Approval: 22/12 /2010 Rev. No.: 00
Approved By: Chairman Of Accreditation Next Revision Date : 25/12 /2012
Steering Committee
Page 4 of 11
Date of Approval: 25/12 /2010

a STAT test:
2.1:The HCP in Laboratory or X-Ray/Radiology Departments shall follow the reporting of critical
tests results according to turn around time (TAT).
2.2: The HCP receiver is to write the result as stated by the Staff giving the result.
2.3: Then the same receiver reads-back the result to the one giving the result.
2.4: The giver shall confirm that result is read correct.
3: Repeat-back is done only in certain situations such as code blue or in the OR when it may not
be feasible to do a formal read-back but repeat-back shall be used.
3.1: The nurse or HCP assisting the doctor repeats-back the order without writing it.
3.2: Then the doctor confirms that the repeat-back is correct by saying i.e. OK.
3.3: Another nurse who is at the scene can list down the repeat-back.
4: During Endorsement:
4.1: Use SBARQ technique. (Refer to figure 2 for detailed information about SBARQ; and
Attachment “A” for the form in use.)
4.2: Allocate sufficient time for communicating important information to ask and respond to
questions without interruptions wherever possible (repeat-back and read-back steps should be
included in the hand-over process).
5: Involving patient in communication:
5.1: Assess patient and family knowledge and absorption of understanding due to low health literacy
and language barrier.
5.2: Teach-back or return demonstration involves asking the patient to describe what he/she has just
heard i.e. communicating critical information, making aware of prescribed medications, doses, and
required time between medications.
5.3: Provide information regarding the patient’s status, medications, treatment plans, advance
directives, and any significant status changes to gain their cooperation.
5.4: Inform patients who are the responsible provider of care during each shift and who to contact, if
they have a concern about the safety or quality of care.
5.5: Provide patients with the opportunity to read their own medical record as a patient safety
strategy.
5.6: Create opportunities for patients and family members to address any medical care questions or
concerns with their health-care providers.
5.7: Inform patients and family members of the next steps in their care, so they can if necessary
communicate this to the care provider on the next shift.
5.8: At the time of hospital discharge the patient and the next health-care provider (if for transfer to
other facility) shall be given key information regarding:
 when the discharge will take place to alleviate their anxiety;
 discharge diagnoses, treatment plans, and test results;
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Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures Document Title:
Originating Entity : quality performance
Effective Communication
and patient safety
Date Originated: 22/11 /2010 Document No.: POL-ACC-001-3
Approved By: Chairman Of Quality Date Revised: 25/12 /2010
Performance And Patient Safety
Date of Approval: 22/12 /2010 Rev. No.: 00
Approved By: Chairman Of Accreditation Next Revision Date : 25/12 /2012
Steering Committee
Page 5 of 11
Date of Approval: 25/12 /2010

 take home medication/s with instructions on how to take them;

 how to contact the hospital, in case of treatment reactions;
 after discharge follow up revisit to the clinic.
5.9: Communication between organizations that are providing care to the same patient in parallel
shall be established especially before patient’s transfer to that facility.
VII. Forms Required:
 “Do not use” list
 Form VTORB001

VIII. Reference:
 INTERNATIONAL PATIENT SAFETY GOALS (Version 2007)

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Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures Document Title:
Originating Entity : quality performance
Effective Communication
and patient safety
Date Originated: 22/11 /2010 Document No.: POL-ACC-001-3
Approved By: Chairman Of Quality Date Revised: 25/12 /2010
Performance And Patient Safety
Date of Approval: 22/12 /2010 Rev. No.: 00
Approved By: Chairman Of Accreditation Next Revision Date : 25/12 /2012
Steering Committee
Page 6 of 11
Date of Approval: 25/12 /2010

Form VTORB001

NAME: Date:
VERBAL/TELEPHONE
ORDERS PIN : Room No:
S=Situation B=Background Assessment R=Recommendation Q=Question
I am: Unit:
S I am calling about (patient’s name):
The reason why I am calling is:
PIN:

B Admission Diagnosis is:

Relevant medical history:
Patient assessment e.g. vital signs:
admitted on:

A The current problem:

R Write the order, include timescale, the name of person giving the order:

Feel free to question, if any further inquiry:

Receiving HCP, Title:

Signature/Badge No.:
 Ordering Physician Signature/Dr’s. Code (Use Badge, if #
HCP):
 Reporting HCP:
ATTENTION:
 Incase of prescribing medication, the order should be verified to include: drug name/s,
dose, route, and frequency.
 HCP Receiver shall first WRITE THE ORDER, REPEAT-BACK, and WAIT FROM THE
ORDERING PHYSICIAN FOR CONFIRMATION THAT THE ORDER IS CORRECT.
 Physician to sign the order within the same shift or if possible within 24 hours maximum.
Confidential Information
Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures Document Title:
Originating Entity : quality performance
Effective Communication
and patient safety
Date Originated: 22/11 /2010 Document No.: POL-ACC-001-3
Approved By: Chairman Of Quality Date Revised: 25/12 /2010
Performance And Patient Safety
Date of Approval: 22/12 /2010 Rev. No.: 00
Approved By: Chairman Of Accreditation Next Revision Date : 25/12 /2012
Steering Committee
Page 7 of 11
Date of Approval: 25/12 /2010

Appendix 1

4.0. LIST OF “DO NOT USE” ABBREVIATIONS, SYMBOLS, AND DOSAGE:

4.1. Abbreviation Intended Misinterpretation Correction
Meaning
ug Microgram Mistaken as “mg” Use “mcg”
AD, AS, AU Right ear, left Mistaken as OD, OS, OU Use “right ear,” “left
ear, each ear (right eye, left eye, each eye) ear,” or “each ear”
OD, OS, OU Right ear, left Mistaken as AD, AS, AU Use “right ear,” “left
ear, each ear (right eye, left eye, each eye) ear,” or “each ear”
BT Bedtime Mistaken as “BID” (twice Use “bedtime”
daily”
cc Cubic Mistaken as “u” (units) Use “ml”
centimeters
D/C Discharge or Premature discontinuation of Use “discharge” and
discontinue medications if D/C “discontinue”
(intended to mean
“discharge”) has been
misinterpreted as
“discontinued” when
followed by a list of
discharge medications
IJ Injection Mistaken as “IV” or Use “injection”
“intrajugular”
IN Intranasal Mistaken as “IM” or “IV” Use “intranasal” or
“NAS”
HS Half-Strength at Mistaken as bedtime Use “half-strength” or
hs bed-time, hours of Mistaken as half-strength “bedtime”
sleep
IU International Unit Mistaken as IV Use “units”
(intravenous) or 10 (ten)
o.d. or OD Once Daily Mistaken as “right eye” (OD- Use “daily”
oculus dexter), leading to oral
liquid medications
administered in the eye
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Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures Document Title:
Originating Entity : quality performance
Effective Communication
and patient safety
Date Originated: 22/11 /2010 Document No.: POL-ACC-001-3
Approved By: Chairman Of Quality Date Revised: 25/12 /2010
Performance And Patient Safety
Date of Approval: 22/12 /2010 Rev. No.: 00
Approved By: Chairman Of Accreditation Next Revision Date : 25/12 /2012
Steering Committee
Page 8 of 11
Date of Approval: 25/12 /2010

OJ Orange Juice Mistaken as OD or OS (right Use “orange juice”

or left eye); drugs meant to
be diluted in orange juice
may be given in the eye
per os By mouth, orally The “os” can be mistaken as Use “PO” “by mouth,”
“left eye” (OS-oculus or “orally”
sinister)
q.d. or QD Every day Mistaken as q.i.d., especially Use “daily’
if the period after the “q” or
the tail of the “q” is
misunderstood as an “i”
qhs Nightly at bedtime Mistaken as “qhr” or every Use “nightly”
hour
qn Nightly or at Mistaken as “qh” (every Use “nightly” or “at
bedtime hour) bedtime”
q.o.d. or QOD Every other day Mistaken as “q.d.” (daily) or Use “every other day”
“q.i.d. (four times daily) if
the “o” is poorly written
q1d Daily Mistaken as q.i.d. (four Use “daily”
times daily)
q6PM,etc. Every evening at 6 Mistaken as every 6 hours Use “6 PM nightly” or
PM 6 PM daily”
SC, SQ, sub q Subcutaneous SC mistaken as SL Use “subcut” or
(sublingual); SQ mistaken as “subcutaneously”
“5 every;” the “q” in “sub q”
has been mistaken as
“every” (e.g., a heparin dose
ordered “sub q 2 hours
before surgery”
misunderstood as every 2
hours before surgery)
ss Sliding Scale Mistaken as “55” Spell out “sliding
(insulin) or ½ scale;” use “one-half”
(apothecary) or “½”
SSRI Sliding Scale Mistaken as selective- Spell out “sliding scale
Regular Insulin serotonin reuptake inhibitor (insulin)”

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Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures Document Title:
Originating Entity : quality performance
Effective Communication
and patient safety
Date Originated: 22/11 /2010 Document No.: POL-ACC-001-3
Approved By: Chairman Of Quality Date Revised: 25/12 /2010
Performance And Patient Safety
Date of Approval: 22/12 /2010 Rev. No.: 00
Approved By: Chairman Of Accreditation Next Revision Date : 25/12 /2012
Steering Committee
Page 9 of 11
Date of Approval: 25/12 /2010

SSI Sliding Scale Mistaken as Strong Solution

Insulin of Iodine (Lugol’s)
i/d One daily Mistaken as “tid” Use “1 daily”
TIW or tiw 3 times a week Mistaken as “3 times a day” Use “3 times weekly”
or “twice in a week”
U or u Unit Mistaken as number of 0 or Use “unit”
4, causing a 10-fold
overdose or greater (e.g.,4U
seen as“40”or 4u seen as
“44”); mistaken as“cc”given
in volume instead of
units(e.g.,4u seen as 4cc)
4.2. Dose
Designations Intended
Misinterpretation Correction
and Other Meaning
Information
Trailing zero 1 mg Mistaken as 10 mg if the Do not use trailing
after decimal decimal point is not seen zeros for doses
point expressed in whole
(e.g., 1.0 mg) numbers
“Naked” 0.5 mg Mistaken as 5 mg if the Use zero before
Decimal point decimal point is not seen decimal point when the
(e.g., 5 mg) dose is less than a
whole unit
Drug name and Inderal 40 mg Mistaken as Inderal 140 mg Place adequate space
dose run between the drug name,
together Tegretol 300 mg Mistaken as Tegretol 1300 dose, and unit of
(especially mg measure
problematic for
drug names that
end in “I” such
as Inderal40 mg;
Tegretol300 mg)
Numerical dose 10 mg The “m” is sometimes Place adequate space
and unit of mistaken as zero or two between the dose and
measure run 100 mL zeros, risking a 10- to 100- unit of measure
together (e.g., fold overdose
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Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures Document Title:
Originating Entity : quality performance
Effective Communication
and patient safety
Date Originated: 22/11 /2010 Document No.: POL-ACC-001-3
Approved By: Chairman Of Quality Date Revised: 25/12 /2010
Performance And Patient Safety
Date of Approval: 22/12 /2010 Rev. No.: 00
Approved By: Chairman Of Accreditation Next Revision Date : 25/12 /2012
Steering Committee
Page 10 of 11
Date of Approval: 25/12 /2010

10mg,
100mgmL)
Abbreviations mg The period is unnecessary Use mg, mL, etc
such as mg. or and could be mistaken as the without a terminal
mL, with a mL number 1 if written poorly period
period following
the abbreviation
Large doses 100,000 units 100000 has been mistaken Use commas for dosing
without properly as 10,000 or 1,000,000; units at or above 1,000,
placed commas 1,000,000 units 1000000 has been mistaken or use words such as
(e.g. 100000 as 100,000 100 “thousand” or 1
units; 1000000 million” to improve
units) readability
4.3. Drug Name Intended
Misinterpretation Correction
Abbreviations Meaning
Use complete drug
Mistaken as cytarabine (ARA
ARA A vidarabine name
C)
AZT Use complete drug name
Zidovudine Mistaken as azathioprine or
(Retrovir) aztreonam
CPZ Compazine Mistaken as chlorpromazine Use complete drug name
(prochlorperazine)
DPT Demerol- Mistaken as diphtheria- Use complete drug name
Phenergan- pertusis-tetanus
Thorazine
DTO Diluted tincture of Mistaken as tincture of opium Use complete drug name
opium, or
deodorized
tincture of opium
(Paregoric)
HCI Mistaken potassium chloride Use complete drug name
Hydrochloric acid
(The “H” is misinterpreted as unless expressed as a
or hydrochloride
“K”) salt of a drug
HCT Mistaken as Use complete drug name
hydrocortisone
hydrochlorothiazide
HCTZ hydrochlorothiazi Mistaken as hydrocortisone Use complete drug name
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Not to be Reproduced / Disclosed Without Prior Written Approval
 Policies & Procedures Document Title:
Originating Entity : quality performance
Effective Communication
and patient safety
Date Originated: 22/11 /2010 Document No.: POL-ACC-001-3
Approved By: Chairman Of Quality Date Revised: 25/12 /2010
Performance And Patient Safety
Date of Approval: 22/12 /2010 Rev. No.: 00
Approved By: Chairman Of Accreditation Next Revision Date : 25/12 /2012
Steering Committee
Page 11 of 11
Date of Approval: 25/12 /2010

de (seen as HCT250 mg)

MgSO4 Magnesium Mistaken as morphine sulfate Use complete drug name
sulfate
MS, MS04 Morphine sulfate Mistaken as morphine sulfate Use complete drug name
MTX methotrexate Mistaken as mitoxantrone Use complete drug name
PCA procainamide Mistaken as patient controlled Use complete drug name
analgesia
PTU propylthiouracil Mistaken as mercaptopurine Use complete drug name
T3 Tylenol with Mistaken as liothyronine Use complete drug name
codeine No.3
TAC triamcinolone Mistaken as tetracaine, Use complete drug name
Adrenaline, cocaine
TNK TNKase Mistaken as “TPA” Use complete drug name
ZnSO4 Zinc sulfate Mistaken as morphine sulfate Use complete drug name

4.4. Stemmed Intended

Misinterpretation Correction
Drug Names Meaning
“Nitro” drip Nitroglycerin Mistaken as sodium Use complete drug name
infusion nitroprusside infusion
“Norflox” norfloxacin Mistaken as Norflex Use complete drug name
“IV Vanc” Intravenous Mistaken as Invanz Use complete drug name
vancomycin
4.5. SYMBOLS POTENTIAL PROBLEM USE INSTEAD
> (GREATER Misinterpreted as # 7 (7) or letter L. Write “greater than”
THAN) Confused for one another
< (LESS THAN)
Apothecary units Unfamiliar to many practitioners and Use metric units
confused with metric drugs

@ Mistaken for number “2” (two) Write “at”

cc Mistaken for U(units) when poorly written Write “ml” or micrograms

µg Mistaken for mg (milligrams) resulting in Write “mcg” or

one thousand-fold overdose “micrograms”
Reference: MCI.13: Standard Abbreviations

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