1. Handovers: a measurement and interventional framework Eleanor Robertson MB ChB, BMSc (hons), MRCS Clinical Research Fellow QRSTU, University of Oxford

2. 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…’

3. Swiss cheese model http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html Surgical Mark Pre-operative checklist Consent form Awake patient WHO checklist Out patient clinic letter Wrong site surgery example Surgeon previously met patient

4. 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

5. 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?’

6. 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/

7. 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

8. 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

9. 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?

10. 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

11. NHS People & Tasks Culture Money Training Governmental policy

12. 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’?

13. COUGH http://pbjpaulito.posterous.com/?tag=birdflu http://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

14. 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

15. ‘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 Carayon P et al. Qual Saf Health Care 2006;15:i50-i58

16. Royal college of surgeons http://www.rcseng.ac.uk/service_delivery/working-time-directive/docs/Safe%20handovers.pdf

17. Royal college of anaesthetists handover audit standards http://www.rcoa.ac.uk/docs/ARB-RecoveryHandover.pdf

18. 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?

19. Task for us Use the SEIPS model Attach….. ▫Symptoms ▫Investigations ▫Treatment …..to appropriate section on model Discussion

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