1. Patient Safety & Clinical Handover
Kiaran Flanagan, Consultant Acute Physician
Acute Medicine Team

3. Acute Medicine

4. Acute Medicine Busy Lots of sick people Lots of doctors
Wide spectrum of practice
You have to keep you eye on the ball...
HIGH RISK AREA OF CLINICAL PRACTICE

5. What is our minimum standard?
“The very first requirement in a hospital is it that it should do the sick no harm”
Notes on Hospitals, 1863

6. What is patient safety?
“The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare”

7. Or ...
Actions undertaken by individuals and organizations to protect health care recipients from being harmed by the effects of health care services

9. No needless pain or suffering No unwanted waits No helplessness
Our Aim
No needless deaths
No needless pain or suffering
No unwanted waits
No helplessness
No waste
For anyone....

10. The scale of the problem
1 in 10 patients suffer adverse event
850,000 adverse events in hospitals/ year
8% result in death
6% result in permanent disability
Costs £400 million/ year in compensation

12. Factors Affecting Patient Safety
Task
Individual
Team
Working Conditions
Organisational
Governmental & Regulatory

13. A couple of little stories...

14. Fell over on the way to the shed
Collapsed with LOC on the way to the shed
Haemodynamically compromised
Malaena apparent
Resuscitated
“HIGH RISK GI BLEED”
Stabilised until morning
Not picked up as sick on WR
Could go home
Discharged stopped
OGD reorganised
In OGD went to toilet collapsed with massive bleed and died

15. Fell over on the way to the bathroom
Tripped over cat
Chest pain ? rib fracture
Paramedics kept at home
1 week later ED with chest pain
?ACS
Seen by consultant 16 hours later
Fractured ribs, abn CXR and abdominal pain
CT 5 hours later
Chest drain
Died after 12 hours

16. Fell over on the way to the kitchen
Simple fall, low back pain
ED, not steady - admit
X ray thoracic spine NAD
48 hours later opoids for pain
Transferred under AMT
Picked up next morning (Fri)
“Not right”, tests ordered
Not seen over weekend
Cardiac arrest (Mon am) on ward round

17. Its all about cheese...

18. Never Events

19. Human Factors

20. What is Clinical Handover?
The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis
National Patient Safety Agency, 2005

21. Why Clinical Handover?
Continuity of sufficient and relevant information(and appropriate action) to suitably experienced clinicians is vital to the safety of our patients

22. Responsibility & Accountability
“Individuals and organisations have a shared responsibility to ensure that safe continuity of information and responsibility takes place”
“Information provided during handovers influences the delivery of care for the whole shift”

23. What it’s supposed to achieve
Sufficient and relevant information should be exchanged
Clinically unstable patients made known to senior and covering clinicians
Unstable patients receive review
Juniors adequately briefed of concerns from personnel and previous shifts
At risk areas/ situations identified

24. Getting practical Morning Clinical Handover 08:30 CDU
Evening Clinical Handover 17:00 ED Seminar Room
Clinical Handover :30 Control Room

25. Even with the best planning in the world...