18 Matt Inada-Kim - Clinical Human Factors Group

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
Putting patient safety first
Why is this important ?
• Safety Critical
• To allow Continuity
• Patient Journey
• Shift to shift
• To avoid Chinese Whispers...
The Baton change metaphor sums up what improvement practice and training can
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
…from one team to another
Tri Modal Types
One location to another
e.g. Home to hospital
Shift change
e.g. Early to late shift in the same department
Specialty to specialty referral
e.g. Ambulance to AE
Tri modal Methods
Pure verbal handover results in 67% of information being lost after the first handover.
97% is lost by the fifth handover
Groups taking notes retained 87% of the important data, with 85.5% retained after the fifth handover
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
Reduces duplication, 3 way repeated conversations
Promoting involvement of the right person, first time
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
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
Being Human
clinical skills
Who owns Handover ?.
Human Machine ?
Situational Awareness
Staffing Adequacy
Dampened Hierarchy
Acceptance of Human Limitations
Pathways / Guidelines
Clear Processes
Formal Structured handover meeting
Sterile Cockpit
Standardised Procedures/Geography
Well trained staff
Engineering (Handover Tools)
Equipment (PDAs, Wi Fi, Computer interfaces)
Multimodal Handover / Communication Templates
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
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
What is happening at the present time?
What are the circumstances leading up to this situation?
What do I think the problem is?
What should we do to correct the problem?
Bad Cop
Good Cop
Good Communication
Mr Jones is a 88 year old man with Severe back pain secondary to a pathological
fracture of T6 and confusion.
This is unclear, but he may have been coughing recently, there is no collateral.
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.
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”