Web Ex November 3 rd 2011

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 Putting patient safety first

Why is this important ?

• Safety Critical • To allow Continuity • Patient Journey • Shift to shift • To avoid Chinese Whispers...

Metaphors The Baton change metaphor sums up what improvement practice and training can accomplish.

Medical Handover is Far more complex is Far less standardised is 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 ?

Handover is…

Safe transfer

of

Information

+

Responsibility

…from one team to another

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

Written

Groups taking notes retained 87% of the important data, with 85.5% retained after the fifth handover

Computerised

A 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

Efficient

Reduces duplication, 3 way repeated conversations

Effective

Promoting involvement of the right person, first time

Safe

To 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.

Hierarchy Gradients 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.”

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 Formal clinical skills Fallibility Leadership

Being Human

Teamwork Training Who owns Handover ?.

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

Good Communication

Situation

Mr 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.

Assessment

He’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”