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Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation Sepsis Project Lead Fellow NHS III, Advocate of CHFG Web Ex November 3 rd 2011

Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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Page 1: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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

Page 2: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

Why is this important ?

• Safety Critical

• To allow Continuity• Patient Journey• Shift to shift

• To avoid Chinese Whispers...

Page 3: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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

Page 4: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

Safe transferof

Information +

Responsibility

…from one team to another

Handover is…

Page 5: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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

Page 6: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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.

Page 7: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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

Page 8: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

Human Factors

Page 9: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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.

Page 10: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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

Page 11: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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

http://en.wikipedia.org/wiki/File:KLM_Magazine_that_contains_Captain_Jacob_Veldhuyzen_Van_Zanten.jpg
Page 12: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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

Page 13: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

Human Machine ?

Page 14: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

Personnel

Situational Awareness

Communication

Staffing Adequacy

Dampened Hierarchy

Acceptance of Human Limitations 

Page 15: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

Systems

Pathways / Guidelines

Clear Processes

Formal Structured handover meeting

Sterile Cockpit

Standardised Procedures/Geography

Well trained staff

Page 16: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

Devices

Engineering (Handover Tools)

Equipment (PDAs, Wi Fi, Computer interfaces)

Multimodal Handover / Communication Templates

Telemedicine

Measurement

Page 17: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation
Page 18: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation
Page 19: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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

Page 20: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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

Page 21: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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?

Page 22: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

Bad Cop

Page 23: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

Good Cop

Page 24: Putting patient safety first Handover and Clinical Human Factors Matt Inada-Kim Acute Medicine Lead, WEHCT, NHS South Central Patient Safety Federation

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


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