Handover and Clinical Human Factors

1. Web Ex November 3rd 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

2. Why is this important ? • Safety Critical • To allow Continuity • Patient Journey • Shift to shift • To avoid Chinese Whispers...

3. 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 ?

4. Handover is… Safe transfer of Information + Responsibility …from one team to another

5. 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

6. 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.

7. 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

8. Human Factors

9. A Middle aged father of two… • Plendil Ca channel blocker • Isordil Long acting Nitrate • 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.

10. 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.”

11. 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

12. Analysis Handover Failures Fallibility No Standardisation No Required quality No Data Leadership Reliance on Diagnostics Large Hierarchies Being Human Unsafe systems No Policy Teamwork No Tools Formal Training clinical skills Who owns Handover ?.

13. Human Machine ?

14. Personnel Situational Awareness Communication Staffing Adequacy Dampened Hierarchy Acceptance of Human Limitations

15. Systems Pathways / Guidelines Clear Processes Formal Structured handover meeting Sterile Cockpit Standardised Procedures/Geography Well trained staff

16. Devices Engineering (Handover Tools) Equipment (PDAs, Wi Fi, Computer interfaces) Multimodal Handover / Communication Templates Telemedicine Measurement

19. 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

20. 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

21. 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?

22. Bad Cop

23. Good Cop

24. 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”