Handovers: a measurement and interventional frameworkEleanor 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

Surgical

Mark

Pre-operative checklist

Conse

nt fo

rmAwake patient

WHO 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 TrustWard

People &

Tasks

Culture

Money Training

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

Many thanks….

Any comments or further chat…..…..eleanor.robertson@nds.ox.ac.uk