Putting patient safety first
Handover and Clinical Human Factors
Matt Inada-KimAcute Medicine Lead, WEHCT,
NHS South CentralPatient Safety Federation Sepsis Project Lead
Fellow NHS III, Advocate of CHFG
Web Ex November 3rd 2011
Why is this important ?
• Safety Critical
• To allow Continuity• Patient Journey• Shift to shift
• To avoid Chinese Whispers...
The Baton change metaphor sums up what improvement practice and training can accomplish.
Medical Handover is Far more complexis Far less standardisedis within a Far more safety critical industry but we train our clinicians in handover Far less…
Where is the Research and Evidence ?
How do we measure the process ?
Metaphors
Safe transferof
Information +
Responsibility
…from one team to another
Handover is…
Tri Modal Types
Geographical One location to another e.g. Home to hospital
Chronological Shift change e.g. Early to late shift in the same department
Silo Specialty to specialty referral e.g. Ambulance to AE
Tri modal Methods
Verbal Pure verbal handover results in 67% of information being lost after the first handover.
97% is lost by the fifth handover
WrittenGroups taking notes retained 87% of the important data, with 85.5% retained after the fifth handover
ComputerisedA computerized handover tool supporting Verbal / Written
The preferred system is probably is at least bimodal.
The optimal one being tri modal comprising of all of the above.
Tri modal Goals
EfficientReduces duplication, 3 way repeated conversations
EffectivePromoting involvement of the right person, first time
SafeTo reduce the commonest reason for Adverse Events
Human Factors
A Middle aged father of two…
(a) Plendil Ca channel blocker
(b) Isordil Long acting Nitrate
(c) Zestril ACE inhibitor
The Physician meant Isordil 20 mg QDS
The Pharmacist read it as 20 mg Plendil QDS
The starting dose of Plendil is 10mg OD..
The patient devloped a critically low BP and died within the week.
Cleese: (looking down) “I look down on him because I am upper class.”
Barker: (looking up) “I look up to him because he is upper class,” (looking down) “but I look down to him because he is lower class.” (looking straight) “I am middle class.”
Corbett: “I know my place.”
Cleese: (looking down) “I get a feeling of superiority over them.”
Barker: (looking up) “I get a feeling of inferiority from him but a (looking down) feeling of superiority over him.”
Corbett: (looking up) “I get a pain in the back of my neck.”
Hierarchy Gradients
Captain Jacob Van Zantent, KLM-747, Tenerife, 1977
All 234 passengers and 14 crew members in the KLM plane died, while 326 passengers and 9 crew members aboard the Pan Am flight were also killed
Analysis Handover Failures
Fallibility
No PolicyBeing HumanBeing Human
Unsafe
systems
No Required quality
Reliance on Diagnostics
No Tools
No Data
Formal
Teamwork
Large Hierarchies
Training
No Standardisation
clinical skillsWho owns Handover ?.
Leadership
Human Machine ?
Personnel
Situational Awareness
Communication
Staffing Adequacy
Dampened Hierarchy
Acceptance of Human Limitations
Systems
Pathways / Guidelines
Clear Processes
Formal Structured handover meeting
Sterile Cockpit
Standardised Procedures/Geography
Well trained staff
Devices
Engineering (Handover Tools)
Equipment (PDAs, Wi Fi, Computer interfaces)
Multimodal Handover / Communication Templates
Telemedicine
Measurement
Communication
How do we improve the transfer of information?
How do we encourage junior staff to speak up and be heard if they perceive a possible Adverse Event ?
How do we avoid a Tenerife disaster within our hospitals ?
SBAR- A shared mental model for improving communication between clinicians
Journal on Quality and Patient Safety March 2006
Anyone here a doctor who speaks nurse?HSJ 23
SBAR: A shared mental model for improving communication between clinicians
Journal on Quality and Patient Safety March 2006
SBAR
Situation: What is happening at the present time?
Background: What are the circumstances leading up to this situation?
Assessment: What do I think the problem is?
Recommendation: What should we do to correct the problem?
Bad Cop
Good Cop
SituationMr Jones is a 88 year old man with Severe back pain secondary to a pathological
fracture of T6 and confusion.
Background This is unclear, but he may have been coughing recently, there is no collateral.
AssessmentHe’s got focal tenderness on T6, the T spine Xray confirms fracture, he’s also slightly
hypoxic with sats of 90% on room air, and has some left basal crackles. His GCS is 14/15 and he’s disorientated.
Recommendations
ED SHO- “I don’t know why he’s developed a pathological fracture, but he can’t cope at home with this and his (possibly new) confusion. His bloods have all gone but are not back. He’s needing morphine to control the back pain and I don’t know if that’s contributed to his confusion.”
Med Reg- “Can you get an chest Xray and an ABG on his way round to us, he may have a pneumonia or intrathoracic malignancy. If he has evidence of pneumonia please first dose him with Ben Pen and clarithro, if he’s not allergic.
ED SHO- “Sure, so Ben Pen and clarithro if he’s got a pneumonia”
Good Communication