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Handovers: a measurement and interventional framework
Eleanor Robertson MB ChB, BMSc (hons), MRCSClinical Research FellowQRSTU, University of Oxford
Healthcare mindset‘If I were there, that would have never happened.’‘if only they had tried harder…’
Blame culture is still prevalent within healthcare
Dekker, ‘the field guide to understanding human error.’
‘which way?!’‘of course, the outcome was inevitable…’
Swiss cheese model
http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html
Surgica
l
Mark
Pre-operative
checklist
Con
sent
form
Awake patient
WH
O checklist
Out patient clinic letter
Wrong site surgery exampleSurgeon
previously met
patient
In healthcare
•Are we too dependant upon people making last minute saves?▫Rewards
•The benefits and rewards of upstream actions are difficult to pinpoint▫Extra effort often goes unnoticed ▫The system is hungry
Definition of handover
‘‘The transfer of professional responsibility and accountability for some or all aspects of the care of a patient, or group of patients, to another person or professional group on a temporary or permanent basis.’’*
*National Patient Safety Agency. Safe handover: safe patients. Guidance on clinical handover for clinicians and managers. London: BMA, 2004
‘can you watch him for a minute while I’m on my break?’
‘this is Mr Jones, he was found cold and unresponsive at 08.10 by his neighbour….’
‘This young man has had a right knee arthroscopy. Same as usual. OK?’
‘can you check room 5’s trop t at 10pm?’
‘Hi there Dr Ransom, this is Dr Robertson from St Cross Hospital, we were wondering if you would be able to admit Mrs Smith to the cottage hospital for recuperation?’
Handover education• Only taught as communication skill• Historically given low priority• Once qualified
▫ Apprentice learning model▫ Learn through doing
http://caracaschronicles.com/2010/05/18/dropping-the-exchange-market-baton/
European Working Time Directive
•Handovers have always existed•Cruciality of handover brought in to sharp
focus
http://www.bma.org.uk/images/safehandover_tcm41-20983.pdf
What does ‘right’ look like?
http://www.rcplondon.ac.uk/sites/default/files/acute-medicine-toolkit-may-2011.pdfhttp://www.rcseng.ac.uk/service_delivery/working-time-directive/docs/Safe%20handovers.pdf
http://www.gmc-uk.org/static/documents/content/GMP_0910.pdf
Do mnemonics hold the answer?
Cost Implications
The pilot has been cost neutral and a national rollout would involve poster printing only.
Is genuine change this easily obtained?
Central themes•Handover is still unreliable
▫Point of weakness in clinical care
•Approaches try to tackle the moment or handover meeting
•However, handover is nestled within a
wider context
NHS
NHS TrustWardPeople &
Tasks
Culture
MoneyTraining
Governmental policy
Comparison
•The art of clinical medicine is turning a symptom in to a diagnosis
•Can we apply the same mentality to patient safety?
•What clues from a handover equate to symptoms of underlying ‘disease’?
COUGH
http://pbjpaulito.posterous.com/?tag=birdfluhttp://brccbio205sp11.blogspot.com/2011/06/drug-resistant-tuberculosis.html
http://blogs.pitch.com/wayward/arturo%20the%20grain%20of%20pollen.php
Microbiology
assessment
Patch testing
International virology
comparison
Salbutamol lung function
testing
Occupational history &
biopsy
Drug history, stop the medicine
Biopsy
Targeted therapy
Handover is Complex!•Layering of task with information
▫Sensory information•Written augments
▫Varying quality•This fragile moment rests upon
organisational infrastructure▫Distractions, location, shifts, discipline
stress, targets•Patient factors
▫Urgency of work is in constant flux
There is little evidence as to the
actual reliability of clinical handovers.
This is exacerbated by the fact that no universally agreed definitions or methods of studying handover exist.
http://www.health.org.uk/public/cms/75/76/313/587/How%20safe%20are%20clinical%20systems%20full%20length%20publication.pdf?realName=1DVi2p.pdf
‘Investigations’ and ‘treatment’• Video-reflective approach
▫ New handover protocol
• Mnemonics▫ Memory aids and
prompts
• High risk industry translational research▫ ‘non-technical skills’
assessment▫ Airlines, crew resource
management, F1
what & how
what & how
what & how
Carayon P et al. Qual Saf Health Care 2006;15:i50-i58
Royal college of surgeons
http://www.rcseng.ac.uk/service_delivery/working-time-directive/docs/Safe%20handovers.pdf
Royal college of anaesthetists handover audit standards
http://www.rcoa.ac.uk/docs/ARB-RecoveryHandover.pdf
Discussion
•The handover process is difficult to pin down
•Are there new elements for us to observe in the handover process?
•How can we target interventions for
systemic change?
•How do we rate quality in handover?
Task for us
•Use the SEIPS model•Attach…..
▫Symptoms▫Investigations▫Treatment
…..to appropriate section on model
• Discussion
