Transcript TAPS – Training and Action for Patients Safety. Medical
MEDICAL HANDOVER
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TAPS – TRAINING AND ACTION FOR PATIENTS SAFETY.
C. Ruprai, M. Kotlinska, C. Brewer, A. Wilson, Mrs. Jha
What is TAPS?
New training programme
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Helping multi-professional clinical teams
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Develop innovative solutions
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Address common patient safety problems
TAPS programme
• Designed by Bradford Institute for Health Research and panel of active clinicians • Running across Yorkshire (inc. Bradford, Leeds, Sheffield, Doncaster, York) • 10 teams in Hull (inc. Acute Medicine, Orthopaedics, Pharmacy) • O&G team: C. Ruprai, M. Kotlinska, C. Brewer, A. Wilson, Mrs. Jha
Medical handover
Poor handover has repeatedly been implicated as a causative factor in adverse incidents & improvement in handover has been advocated by a number of agencies
Challenges
• • • • • • • EWTD Increase patient load Frequent movement of patients Involvement of multiple specialist team Corridor or inconvenient meeting room Type, formality & information varies Interruptions
TAPS
20 week programme November 2011 – March 2012 4 workshops
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1 st staff survey (Nov. 2011) Results presented at Joined Obs.&Anaest. Meeting
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Handover audit (presented in PNM Dec. 2011)
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TAPS
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Introduction of unified handover sheet (Jan. 2012)
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Weekly audits for 10 weeks
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2nd staff survey
Your perception of handover
• 2 staff surveys (November 2011 and March 2012) • The questionnaire was randomly given to different levels of staff • 46 participants in first one and 33 in the second one • Obstetric, midwifery and anaesthetic members of staff
Results
• Perception of O&G consultant presence at the handover 74% • Evident absence of the anaesthetic staff • 70% - appropriate setting of the handover • Average score for quality of the handover across all staff was 3.6 (scale 1-5)
Weekly audit
Weekly audit
Who is consistently present at handover 1 st survey 2 nd survey
On time start of handover
Who leads handover
Have you been pulled out of handover for non-urgent tasks
Setting (quiet and private)
Overall quality of handover Overall 3.6
Overall 3.8
Is there consistent handover between O&G SpR and consultant between 5-7pm
Conclusion
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Excellent
MDT morning handover involving whole • Clear improvement in many areas of the handover in TAPS process • Audit once a year is not good enough tool in monitoring change and hence should be undertaken more frequently
Recommendations
• Evening face-face communication between obs. SpR and consultant needs to be improved, already has been communicated to senior staff • Repeat staff survey in next several months • Share the experience with others (our ‘journey’ may be used to help improve medical handover in other clinical areas)