Human factors in clinical handover: development and testing of a 'handover performance tool' for doctors' shift handovers

Developing Nursing Standards for Maintaining Shift Handover in the Intensive Care Unit: A Methodological and Cross-Sectional Study

Patient handover, which is a method of moving the clinical data of patients to another individual or professional community, is a high-risk area for the safety of patients due to errors which can happen during staff break time, changeover shifts, and when patients are moved in and out of units. Standards for critical care nurses will improve bedside handover due to the presence of clear plans implemented by nurses who are well informed about them. To develop nursing standards for maintaining handover in the intensive care unit. A methodological and cross-sectional study was conducted at Mansoura University Hospital and included 15 experts and 150 staff nurses. Twelve items were excluded from the tool because their CVR ratio was less than 0.7. Therefore, after eliminating 12 items, the number of tool items produced was 66. The Kaiser-Meyer-Olkin value = 0.713, with the recommended value being 0.6 or above. The cut-off score for the analysis model was 0.3, and the KMO value criterion was greater than 1, which defined eight-factor loadings as the best fit for the results, accounting for 69.5% of the variance. The aim of this study was satisfactorily achieved, with 0.9055 validity and reliability for the handover instrument, which consisted of 60 items with a total reliability score.

Frequency of medical students' language expressing implicit uncertainty in simulated handovers

OBJECTIVES

The aim of this study was to investigate the number and type of implicit expressions of uncertainty by medical students during simulated patient handovers.

METHODS

Eighty-seven volunteer medical students, a convenience sample collected on a first-come, first-served basis, participated in simulated handovers. They each worked with three simulated patients who presented with different chief complaints and personal conditions. The handovers were video recorded and transcribed. A framework of implicit expressions of uncertainty was used to identify and count modifiers that attenuate or strengthen medical information using MAXQDA lexical search. We analysed the findings with respect to the patients' contexts.

RESULTS

Implicit uncertainty expressions which attenuate or strengthen information occurred in almost equal frequency, 1879 (55%) versus 1505 (45%). Attenuators were found most frequently in the category 'Questionable', 1041 (55.4%), strengtheners in the category 'Focused', 1031 (68.5%). Most attenuators and strengtheners were found in the handover of two patients with challenging personal conditions ('angry man', 434 (23.1%) versus 323 (21.5%); 'unfocused woman', 354 (19.4%) versus 322 (21.4%)) and one patient with abnormal laboratory findings ('elevated creatinine', 379 (20.2%) versus 285 (18.9%)).

CONCLUSIONS

Medical students use a variety of implicit expressions of uncertainty in simulated handovers. These findings provide an opportunity for medical educators to design communication courses that raise students' awareness for content-dependent implicit expressions of uncertainty and provide strategies to communicate uncertainty explicitly.

Assessing the quality of patient handovers between ambulance services and emergency department – development and validation of the emergency department human factors in handover tool

Background

Patient handover between prehospital care and the emergency department plays a key role in patient safety. Therefore, we aimed to create a validated tool for measuring quality of communication and interprofessional relations during handover in this specific setting.

Methods

Based on a theoretical framework a comprehensive item pool on information transfer and human factors in emergency department handovers was created and refined in a modified Delphi survey involving clinical experts. Based on a pre-test, items were again revised. The resulting Emergency Department Human Factors in Handover tool (ED-HFH) was validated in a field test at the emergency department of a German university hospital from July to December 2017. The ED-HFH was completed by emergency department and ambulance service staff participating in handovers and by an external observer. Description of item characteristics, exploratory factor analysis, analyses on internal consistency and interrater reliability by intraclass-correlation. Construct validity was analysed by correlation with an overall rating on quality of the handover.

Results

The draft of the ED-HFH contained 24 items, 90 of 102 eligible staff members participated in the field test completing 133 questionnaires on 38 observed handovers. Four items were deleted after analysis of item characteristics. Factor analysis supported a single factor explaining 39% of variance in the items. Therefore, a sum-score was calculated with a possible range between 14 and 70. The median value of the sum-score in the sample was 61.5, Cronbach’s α was 0.83, intraclass-correlation was 0.52, the correlation with the overall rating of hand-over quality was ρ = 0.83 (p ≤ 0.001).

Conclusions

The ED-HFH showed its feasibility, reliability and validity as a measure of quality of information transfer and human factors in handovers between ambulance services  and the emergency department. It promises to be a useful tool for quality assurance and staff training.

Human Performance Analysis of Processes for Retrieving Beidou Satellite Navigation System During Breakdown

Satellite navigation systems provide continuous, timely, and accurate signals of location, speed, and time to users all over the world. Although the running of these systems has become highly automated, the human operator is still vital for its continued operation, especially when certain equipment failures occur. In this paper, we examined 180 incidents of one particular type of equipment failure and the whole recovery process as recorded in the log files from a ground control center of the Beidou satellite navigation system. We extracted the information, including the technical description of the failure, the time when the fault occurred, the full recovery time, and the demographic information of the team members on the shift responsible for responding to the failure. We then transformed these information into the cognitive complexity of the task, time of day, shift handover period, and team skill composition. Multiple regression analysis showed that task complexity and shift handover were key predictors of recovery time. Time of day also influenced the recovery time, during midnight to 4 a.m., operators made longer responses. We also found that the fault handling processes could be improved if the team's most adept member is more skillful at that role than in other teams. We discussed the theoretical and practical implication of this study.

Optimising paediatric afferent component early warning systems: a hermeneutic systematic literature review and model development

OBJECTIVE

To identify the core components of successful early warning systems for detecting and initiating action in response to clinical deterioration in paediatric inpatients.

METHODS

A hermeneutic systematic literature review informed by translational mobilisation theory and normalisation process theory was used to synthesise 82 studies of paediatric and adult early warning systems and interventions to support the detection of clinical deterioration and escalation of care. This method, which is designed to develop understanding, enabled the development of a propositional model of an optimal afferent component early warning system.

RESULTS

Detecting deterioration and initiating action in response to clinical deterioration in paediatric inpatients involves several challenges, and the potential failure points in early warning systems are well documented. Track and trigger tools (TTT) are commonly used and have value in supporting key mechanisms of action but depend on certain preconditions for successful integration into practice. Several supplementary interventions have been proposed to improve the effectiveness of early warning systems but there is limited evidence to recommend their wider use, due to the weight and quality of the evidence; the extent to which systems are conditioned by the local clinical context; and the need to attend to system component relationships, which do not work in isolation. While it was not possible to make empirical recommendations for practice, the review methodology generated theoretical inferences about the core components of an optimal system for early warning systems. These are presented as a propositional model conceptualised as three subsystems: detection, planning and action.

CONCLUSIONS

There is a growing consensus of the need to think beyond TTTs in improving action to detect and respond to clinical deterioration. Clinical teams wishing to improve early warning systems can use the model to consider systematically the constellation of factors necessary to support detection, planning and action and consider how these arrangements can be implemented in their local context.

PROSPERO REGISTRATION NUMBER

CRD42015015326.

Beyond the borders: Lessons from various industries adopted in anesthesiology

Since the first public demonstration of anaesthesia in Boston, USA which happened around 172 years back, the field of anesthesiology has rapidly progressed, with many developments that have improved the quality and safety of anesthesia care. This has enabled tremendous advances in the surgical disciplines and increasing the life expectancy and quality of life of humans. This is a result of learning and constantly evolving. There are several similarities between healthcare and other industries, though there are several distinguishing characteristics that set it apart from other industries. There are a number of safety and quality improvement measures in healthcare which have been influenced by safety practices in other industries. Anaesthesia has been the leader among the medical specialities in adoption of innovative practices from various industries in an effort to advance patient safety, enhance quality of care, reduce waste & inefficiency, and improve customer service and satisfaction. This article emphasises on learnings from other industries in the recent decades, focusing on aviation, high-reliability organizations, car manufacturing, telecommunication, car racing, entertainment, and retail. Learning and implanting the best practices from these industries can bring about a paradigm shift in health care industry. It has a potential to improve efficiency and make anaesthesia safer than ever before in the history of human kind.

Does a multidisciplinary approach have a beneficial effect on the development of a structured patient handover process between acute surgical wards in one of Scotland's largest teaching hospitals?

Background

Effective handover is key in preventing harm.¹ In the Acute Surgical Receiving Unit of Ninewells Hospital, Dundee, large numbers of patients are transferred daily. However, lack of medical handover during transfer means important tasks are missed. Our aim was to understand and reflect on the current system and test changes to improve medical handover.

Aim

Our aim was to ensure that 95% of patients being transferred from the Acute Surgical Receiving Unit receive a basic medical handover within 2 months.

Methods

Initially, we collated issues that were missed when patients were transferred. These data coupled with questionnaire data from members of the team fed into the creation of a handover tool. We proposed to link our tool with the nursing handover, hence creating one unified handover tool. We completed six full Plan-Do-Study-Act (PDSA) cycles (two on communication to aide handover and four on the tool itself) to assess and develop our tool.

Results

By our final PDSA cycle, 84% (33/39) of the patients had a handover, meaning no tasks were missed during transfer. After 4 months, 9 out of 10 staff felt that the introduction of the handover sheet made the handover process smoother and 8 out of 10 felt that the handover sheet improved patient safety and quality of care.

Conclusions

Improving handover can be challenging. However, we have shown that a relatively simple intervention can help promote better practice. Challenges are still present as uptake was only 84%, so work still has to be done to improve this. A wider cultural change involving communication and education would be required to implement this tool more widely.

The feasibility, acceptability and preliminary testing of a novel, low-tech intervention to improve pre-hospital data recording for pre-alert and handover to the Emergency Department

Background

Poor communication during patient handover is recognised internationally as a root cause of a significant proportion of preventable deaths. Data used in handover is not always easily recorded using ambulance based tablets, particularly in time-critical cases. Paramedics have therefore developed pragmatic workarounds (writing on gloves or scrap paper) to record these data. However, such practices can conflict with policy, data recorded can be variable, easily lost and negatively impact on handover quality.

Methods

This study aimed to measure the feasibility and acceptability of a novel, low tech intervention, designed to support clinical information recording and delivery during pre-alert and handover within the pre-hospital and ED setting. A simple pre and post-test design was used with a historical control. Eligible participants included all ambulance clinicians based at one large city Ambulance Station (n = 69) and all nursing and physician staff (n = 99) based in a city Emergency Department.

Results

Twenty five (36%) ambulance clinicians responded to the follow-up survey. Most felt both the pre-alert and handover components of the card were either ‘useful-very useful’ (n = 23 (92%); and n = 18 (72%) respectively. Nineteen (76%) used the card to record clinical information and almost all (n = 23 (92%) felt it ‘useful’ to ‘very useful’ in supporting pre-alert. Similarly, 65% (n = 16) stated they ‘often’ or ‘always’ used the card to support handover. For pre-alert information there were improvements in the provision of 8/11 (72.7%) clinical variables. ​ Results from the post-test survey measuring ED staff (n = 37) perceptions of handover demonstrated small (p < 0.05) improvements in handover in 3/5 domains measured.

Conclusion

This novel low-tech intervention was highly acceptable to ambulance clinician participants, improving their data recording and information exchange processes. However, further well conducted studies are required to test the impact of this intervention on information exchange during pre-alert and handover.

Electronic supplementary material

The online version of this article (10.1186/s12873-018-0168-3) contains supplementary material, which is available to authorized users.

Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010-2013 national accident reports

OBJECTIVES

We sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor non-technical skills, and to support development of a policy to reduce number of such accidents by making recommendations about possible training requirements.

DESIGN

Summaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination.

SETTING

A total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013.

PRIMARY AND SECONDARY OUTCOME MEASURES

The cause of death in fatal medical accidents, categorised into technical skills, non-technical skills and inevitable progress of disease were evaluated. Non-technical skills were further subdivided into situation awareness, decision making, communication, team working, leadership, managing stress and coping with fatigue.

RESULTS

Overall, the cause of death was identified as non-technical skills in 34 cases (46.6%), disease progression in 33 cases (45.2%) and technical skills in two cases (5.5%). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified as 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team working and three (8.8%) with decision making. These three subcategories, or combinations of them, were identified as the cause of death in 33 cases (97.1%).

CONCLUSIONS

Poor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for reducing accidents, and training in particular subcategories of non-technical skills may be especially relevant.

Feedback and Assessment Tools for Handoffs: A Systematic Review

BACKGROUND

Resident handoff communication skills are essential components of medical education training. There are no previous systematic reviews of feedback and evaluation tools for physician handoffs.

OBJECTIVE

We performed a systematic review of articles focused on inpatient handoff feedback or assessment tools.

METHODS

The authors conducted a systematic review of English-language literature published from January 1, 2008, to May 13, 2015 on handoff feedback or assessment tools used in undergraduate or graduate medical education. All articles were reviewed by 2 independent abstractors. Included articles were assessed using a quality scoring system.

RESULTS

A total of 26 articles with 32 tools met inclusion criteria, including 3 focused on feedback, 8 on assessment, and 15 on both feedback and assessment. All tools were used in an inpatient setting. Feedback and/or assessment improved the content or organization measures of handoff, while process and professionalism measures were less reliably improved. The Handoff Clinical Evaluation Exercise or a similar tool was used most frequently. Of included studies, 23% (6 of 26) were validity evidence studies, and 31% (8 of 26) of articles included a tool with behavioral anchors. A total of 35% (9 of 26) of studies used simulation or standardized patient encounters.

CONCLUSIONS

A number of feedback and assessment tools for physician handoffs in several specialties have been studied. Limited research has been done on the studied tools. These tools may assist medical educators in assessing trainees' handoff skills.

Implementing web-based ping-pong-type e-communication to enhance staff satisfaction, multidisciplinary cooperation, and clinical effectiveness: A SQUIRE-compliant quality-improving study

BACKGROUND

Frequent multidisciplinary communication is essential in conducting daily radiotherapy (RT) practice. However, traditional oral or paper-based communication has limitations. E-communication has been suggested, but its effects are still not well demarcated in the field of radiation oncology.

OBJECTS

In our web-based integrated information platform, we constructed a ping-pong-type e-communication function to transfer specific notations among multidisciplinary RT staffs. The purpose was to test whether applying this e-communication can increase effectiveness of multidisciplinary cooperation when compared with oral or paper-based practice. Staff satisfaction and clinical benefits were also demonstrated.

DESIGN AND SETTING

A real-world quality-improving study was conducted in a large center of radiation oncology.

PARTICIPANTS AND DATASET USED

Before and after applying multidisciplinary e-communication (from 2014 to 2015), clinical RT staffs were surveyed for their user experience and satisfaction (n = 23). For measuring clinical effectiveness, a secondary database of irradiated head and neck cancer patients was re-analyzed for comparing RT toxicities (n = 402).

INTERVENTIONS

Applying ping-pong-type multidisciplinary reflective e-communication was the main intervention.

OUTCOME MEASURES

For measuring staff satisfaction, eight domains were surveyed, such as timeliness, convenience, and completeness. For measuring clinical effectiveness of multidisciplinary cooperation, event rates of severe (i.e., grade 3-4) RT mucositis and dermatitis were recorded.

RESULTS

Overall, when compared with oral communication only, e-communication demonstrated multiple benefits, particularly on notation-review convenience (2.00 ± 1.76 vs 9.19 ± 0.81; P < 0.0001).When compared with paper-based practice, e-communication showed statistically significant benefits on all eight domains, especially on notation-review convenience (5.05 ± 2.11 vs 9.19 ± 0.81; P < 0.0001) and convenience of feedback notation (4.81 ± 1.72 vs 8.76 ± 1.09; P < 0.0001).Moreover, staff satisfaction was gradually increased from oral (3.57 ± 1.94), paper-based (5.57 ± 2.06), to e-communication (8.76 ± 0.70; P < 0.0001). Secondary measurement confirmed these observations.Before and after facilitating multidisciplinary cooperation by using e-communication, severe (i.e., grade 3-4) mucositis and dermatitis were decreased from 21.7% to 10% then to 5.1%.

CONCLUSIONS

Replacing oral or paper-based practice with e-communication is useful in facilitating RT multidisciplinary teamwork. Staff satisfaction and clinical effectiveness can be increased.

Interface transition checklists in spinal surgery

ISSUE

Recently, quality tools have been promoted to improve patient safety and process efficiency in healthcare. While surgeons primarily focused on surgical issues, like infection rates or implant design, we introduced pre-admission and preoperative checklists in the early 2000s.

INITIAL ASSESSMENT

To assess the efficiency of these tools in a neurosurgical department, we performed a survey of all spinal instrumentation patients operated in 2011 (n = 147). The results revealed several problems.

CHOICE OF SOLUTION

We consequently redesigned the checklists accompanied by flanking measures, such as written  and online accessible standards. Furthermore, the staff was trained to use the updated quality tools.

IMPLEMENTATION

The measures were implemented in 2012.

EVALUATION

Results were re-evaluated in a second survey in 2013 (n = 162). We found that the use of pre-admission checklists significantly increased from 47 to 96%, while the use of preoperative checklists significantly decreased from 86 to 75%. Within the same period, the quality and completeness of the checklists did, however, increase, so that in 2013, 43% of the patients had a completely processed preoperative checklist, compared to 29% in 2011.

LESSONS LEARNED

The introduction of checklists alone did not in itself guarantee an improved workflow. The introduction must be accompanied by other measures, like written standards and regular training of employees. Otherwise, the positive effect wears off quickly. Nevertheless, we could show that the stringent application of quality tools can induce a sustainable change. Our data further suggest that the clear and traceable delegation of responsibilities is of high importance.

Development, implementation and evaluation of a patient handoff tool to improve safety in orthopaedic surgery

OBJECTIVE

To develop, implement and test the effect of a handoff tool for orthopaedic trauma residents that reduces adverse events associated with the omission of critical information and the transfer of erroneous information.

DESIGN

Components of this project included a literature review, resident surveys and observations, checklist development and refinement, implementation and evaluation of impact on adverse events through a chart review of a prospective cohort compared with a historical control group.

SETTING

Large teaching hospital.

PARTICIPANTS

Findings of a literature review were presented to orthopaedic residents, epidemiologists, orthopaedic surgeons and patient safety experts in face-to-face meetings, during which we developed and refined the contents of a resident handoff tool. The tool was tested in an orthopaedic trauma service and its impact on adverse events was evaluated through a chart review. The handoff tool was developed and refined during the face-to-face meetings and a pilot implementation. Adverse event data were collected on 127 patients (n = 67 baseline period; n = 60 test period).

INTERVENTION

A handoff tool for use by orthopaedic residents.

MAIN OUTCOME MEASUREMENTS

Adverse events in patients handed off by orthopaedic trauma residents.

RESULTS

After controlling for age, gender and comorbidities, testing resulted in fewer events per person (25-27% reduction; P < 0.10).

CONCLUSIONS

Preliminary evidence suggests that our resident handoff tool may contribute to a decrease in adverse events in orthopaedic patients.

Development and testing of the cancer multidisciplinary team meeting observational tool (MDT-MOT)

OBJECTIVE

To develop a tool for independent observational assessment of cancer multidisciplinary team meetings (MDMs), and test criterion validity, inter-rater reliability/agreement and describe performance.

DESIGN

Clinicians and experts in teamwork used a mixed-methods approach to develop and refine the tool. Study 1 observers rated pre-determined optimal/sub-optimal MDM film excerpts and Study 2 observers independently rated video-recordings of 10 MDMs.

SETTING

Study 2 included 10 cancer MDMs in England.

PARTICIPANTS

Testing was undertaken by 13 health service staff and a clinical and non-clinical observer.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Tool development, validity, reliability/agreement and variability in MDT performance.

RESULTS

Study 1: Observers were able to discriminate between optimal and sub-optimal MDM performance (P ≤ 0.05). Study 2: Inter-rater reliability was good for 3/10 domains. Percentage of absolute agreement was high (≥80%) for 4/10 domains and percentage agreement within 1 point was high for 9/10 domains. Four MDTs performed well (scored 3+ in at least 8/10 domains), 5 MDTs performed well in 6-7 domains and 1 MDT performed well in only 4 domains. Leadership and chairing of the meeting, the organization and administration of the meeting, and clinical decision-making processes all varied significantly between MDMs (P ≤ 0.01).

CONCLUSIONS

MDT-MOT demonstrated good criterion validity. Agreement between clinical and non-clinical observers (within one point on the scale) was high but this was inconsistent with reliability coefficients and warrants further investigation. If further validated MDT-MOT might provide a useful mechanism for the routine assessment of MDMs by the local workforce to drive improvements in MDT performance.

Effect of handoff skills training for students during the medicine clerkship: a quasi-randomized study

Continuity is critical for safe patient care and its absence is associated with adverse outcomes. Continuity requires handoffs between physicians, but most published studies of educational interventions to improve handoffs have focused primarily on residents, despite interns expected to being proficient. The AAMC core entrustable activities for graduating medical students includes handoffs as a milestone, but no controlled studies with students have assessed the impact of training in handoff skills. The purpose of this study was to assess the impact of an educational intervention to improve third-year medical student handoff skills, the durability of learned skills into the fourth year, and the transfer of skills from the simulated setting to the clinical environment. Trained evaluators used standardized patient cases and an observation tool to assess verbal handoff skills immediately post intervention and during the student's fourth-year acting internship. Students were also observed doing real time sign-outs during their acting internship. Evaluators assessed untrained control students using a standardized case and performing a real-time sign-out. Intervention students mean score demonstrated improvement in handoff skills immediately after the workshop (2.6-3.8; p < 0.0001) that persisted into their fourth year acting internship when compared to baseline performance (3.9-3.5; p = 0.06) and to untrained control students (3.5 vs. 2.5; p < 0.001, d = 1.2). Intervention students evaluated in the clinical setting also scored higher than control students when assessed doing real-time handoffs (3.8 vs. 3.3; p = 0.032, d = 0.71). These findings should be useful to others considering introducing handoff teaching in the undergraduate medical curriculum in preparation for post-graduate medical training. Trial Registration Number NCT02217241.

Taxonomy of Trauma Leadership Skills: A Framework for Leadership Training and Assessment

PURPOSE

Good leadership is essential for optimal trauma team performance, and targeted training of leadership skills is necessary to achieve such leadership proficiency. To address the need for a taxonomy of leadership skills that specifies the skill components to be learned and the behaviors by which they can be assessed across the five phases of trauma care, the authors developed the Taxonomy of Trauma Leadership Skills (TTLS).

METHOD

Critical incident interviews were conducted with trauma team leaders and members from different specialties-emergency physicians, trauma surgeons, anesthesiologists, and emergency ward nurses-at three teaching hospitals in the Netherlands during January-June 2013. Data were iteratively analyzed for examples of excellent leadership skills at each phase of trauma care. Using the grounded theory approach, elements of excellent leadership skills were identified and classified. Elements and behavioral markers were sorted and categorized using multiple raters. In a two-round verification process in late 2013, the taxonomy was reviewed and rated by trauma team leaders and members from the multiple specialties for its coverage of essential items.

RESULTS

Data were gathered from 28 interviews and 14 raters. The TTLS details 5 skill categories (information coordination, decision making, action coordination, communication management, and coaching and team development) and 37 skill elements. The skill elements are captured by 67 behavioral markers. The three-level taxonomy is presented according to five phases of trauma care.

CONCLUSIONS

The TTLS provides a framework for teaching, learning, and assessing team leadership skills in trauma care and other complex, acute care situations.

Improving the quality of handover by addressing handover culture and introducing a new, multi-disciplinary, team-based handover meeting

Handover is a “major preventable cause of patient harm”[1] and this project aims to improve the quality of night handover within a teaching hospitals general medicine department, resulting in the safe transfer of patient care to the night team.

Quality of handover was assessed both qualitatively, via structured qualitative interviews with trainees and a baseline survey assessing doctor's opinions of night handover, and quantitatively through the collection of a data set during regular observation of night handover.

The initial intervention instituted a new handover meeting with a set time and new location and invited the night nurse practitioner to attend. A prompt card, standardised documentation, defined leadership, and an attendance register were also introduced. Successive PDSA cycles introduced technology to the intervention, enabled the nurse night practitioners to actually attend and re-branded the prompt card as an agenda.

Results show a sustained reduction in length of handover from 70 minutes (n=7) to 34 minutes (n=13) post-intervention as well as a reduction in the number of distractions occurring during each handover from a mean of 14 to a mean of 8.5. An improved quality of handover was also demonstrated with an overall increase in the percentage of task handovers containing hospital number, an admitting diagnosis, comorbidities and a time allocated for the task to be performed of at least 10%. When trainees were surveyed post-implementation they unanimously identified the new handover system as safer than the previous handover process (n=30).

This project demonstrates that replacing an ad-hoc system of handover with a multi-disciplinary, team based approach to handover improves handover quality. In addition it provides a useful guide to introducing a new handover meeting to a department and contains useful lessons on how to combat cultural barriers to change within a department.

Evaluating Outcomes of Electronic Tools Supporting Physician Shift-to-Shift Handoffs: A Systematic Review

BACKGROUND

Multiple organizations have recognized that handoffs are prone to errors, and there has been an increase in the use of electronic health records and computerized tools in health care.

OBJECTIVE

This systematic review evaluates the current evidence on the effectiveness of electronic solutions used to support shift-to-shift handoffs.

METHODS

We searched the English-language literature for research studies published between January 1, 2008, and September 19, 2014, using National Library of Medicine PubMed, EBSCO CINAHL, OvidSP All Journals, and ProQuest PsycINFO. Included studies focused on the evaluation of physician shift-to-shift handoffs and an electronic solution designed to support handoffs. We assessed articles using a quality scoring system, conducted a review of barriers and strategies, and categorized study outcomes into self-report, process, and outcome measures.

RESULTS

Thirty-seven articles met inclusion criteria, including 20 single group pre- and posttest studies; 8 posttest only or cross-sectional studies; 4 nonrandomized controlled trials; 1 cohort study; 1 randomized crossover study; and 3 qualitative studies. Quality scores ranged from 3.5 to 14 of a possible 16. Most articles documented some positive outcomes, with 2 of the 3 studies evaluating patient outcomes yielding statistically significant improvements. The only other study that analyzed patient outcomes showed that interventions other than the electronic tool were responsible for most of the significant improvements.

CONCLUSIONS

The majority of studies supported using an electronic tool, yet few measured patient outcomes, and numerous studies suffered from methodology issues. Future studies should evaluate patient outcomes, improve study design, assess the role of faculty oversight, and broaden the focus to recognize the role of human factors.

Effectiveness of interventions to improve patient handover in surgery: A systematic review

BACKGROUND

Handover of patient care is a critical process in the transfer of information between clinical teams and clinicians during transitions in patient care. The handover process may take many forms and is often unstructured and unstandardized, potentially resulting in error and the potential for patient harm. The Joint Commission has implicated such errors in up to 80% of sentinel events and has published guidelines (using an acronym termed SHARE) for the development of intervention tools for handover. This study aims to review interventions to improve handovers in surgery and to assess compliance of described methodologies with the guidelines of the Joint Commission for design and implementation of handover improvement tools.

METHODS

A systematic review was conducted in line with MOOSE guidelines. Electronic databases Medline, EMBASE, and PsyInfo were searched and interventions to improve surgical handover identified. Intervention types, development methods, and outcomes were compared between studies and assessed against SHARE criteria.

RESULTS

Nineteen studies were included. These studies included paper and computerized checklists, proformas, and/or standardized operating protocols for handover. All reported some degree of improvement in handover. Description of development methods, staff training, and follow-up outcome data was poor. Only a single study was able to demonstrate compliance with all 5 domains guidelines of the of Joint Commission.

CONCLUSION

Improvements in information transfer may be achieved through checklist- or proforma-based interventions in surgical handover. Although initial data appear promising, future research must be backed by robust study design, relevant outcomes, and clinical implementation strategies to identify the most effective means to improve information transfer and optimize patient outcomes.

Appropriateness of requests for human serum albumin at the University Hospital of Palermo, Italy: a prospective study

OBJECTIVE

First, to assess the appropriateness of requests for albumin using current guidelines; second, to evaluate physicians' compliance with this protocol.

DESIGN

Descriptive, prospective study.

SETTING

'Paolo Giaccone' University Hospital in Palermo (Italy).

PARTICIPANTS

The six departments with the highest orders for albumin.

INTERVENTION

An experimental, pharmacist-driven process for daily orders of albumin was activated over a period of 1 month. Pharmacy personnel handed out order forms on six different wards. Physicians were required to select one of a number of intended uses listed on the form.

MAIN OUTCOME MEASURES

Data on albumin and serum protein levels; number of vials and grams of albumin requested/day; number of vials and grams of albumin/day needed to normalize serum albumin levels; informed consent; indications and appropriateness of use.

RESULTS

A total of 126 forms were collected. Mean serum albumin and protein levels of patients in the different wards were close to normal (2.5 and 5 g/dl, respectively). The albumin doses requested by the various wards were 2 to 7 times higher than expected. 37.3% of the requests were for appropriate indications, 40.5% were for occasionally appropriate indications and 18.2% were inappropriate. According to current guidelines, 83.3% of requests were appropriate. 45% of orders from the Intensive Care ward were for inappropriate indications.

CONCLUSIONS

The introduction of a well-defined, flexible pharmacist-driven ordering process for albumin could reduce omissions in albumin indications and aid request assessment. It would allow pharmacists to collaborate with physicians in verifying whether requests are appropriate and whether prescriptions comply with current guidelines.

Observation of handover process in an intensive care unit (ICU): barriers and quality improvement strategy

OBJECTIVE

To describe the characteristics and barriers in the handover process in a medical intensive care unit.

DESIGN

A cross-sectional descriptive study using a checklist to observe nurses and doctors during handover of patients in and out of the intensive care unit.

SETTING

The study was conducted at a 1000-bed tertiary hospital in Singapore. The unit admits all patients under university medicine clusters, except those needing cardiology services.

PARTICIPANTS

Handover between 90 pairs (180 participants)-50 nurse-to-nurse (100 nurses) and 40 doctor-to-doctor (80 doctors)--were passively observed in real time during morning and evening shifts over weekdays.

MAIN OUTCOME MEASURES

The number and types of distractions and their relationship to the time spent during handover, the information included during handover, and the number of working shifts.

RESULTS

The results showed that there were 1.26 (± 1.75) distractions per handover. In 45 (50%) handovers, no distraction occurred. The human factor was the most common distracting factor during handovers, whereas short message service and monitor alarms were not identified as distracting factors. The information included least often was 'do not resuscitate' (DNR). Nurses spent significantly longer during handovers than doctors.

CONCLUSION

The findings provide information for improving the handover process during the transfer of patients in and out of the intensive care unit. Distractions during handovers are common and are associated with longer durations. Nurses and doctors rarely address DNR status during handover of ICU patients in this study.

Simulation and psychology: creating, recognizing and using learning opportunities

PURPOSE OF REVIEW

Psychology is relevant for improving the use of simulation in anesthesiology, as it allows us to describe, explain and optimize the interactions of learners and instructors as well as the design of simulation scenarios and debriefings. Much psychological expertise is not used for simulation in healthcare. This article aims to help bridging the gap between professions.

RECENT FINDINGS

The evidence is building that simulation is effective for learning. Recent psychological work improves the understanding of why this is the case - or why not. Publications range from the elements to be simulated, to optimizing the presentation of scenarios and debriefings to an organizational overview of how simulation can contribute to patient safety, healthcare worker well-beings and quality of care. The psychological analysis helps in capturing the salient characteristics of the tasks to be simulated and in implementing them in a relevant learning setting.

SUMMARY

Using psychology in simulation allows us to create, recognize and use learning opportunities. The motivations of those involved can be taken into account and the simulation activity can be channeled into a goal-oriented direction.

VIDEO ABSTRACT AVAILABLE

See the Video Supplementary Digital Content 1 (http://links.lww.com/COAN/A26).

Interventions employed to improve intrahospital handover: a systematic review

BACKGROUND

Modern medical care requires numerous patient handovers/handoffs. Handover error is recognised as a potential hazard in patient care, and the information error rate has been estimated at 13%. While accurate, reliable handover is essential to high quality care, uncertainty exists as to how intrahospital handover can be improved. This systematic review aims to evaluate the effectiveness of interventions aimed at improving the quality and/or safety of the intrahospital handover process.

METHODS

We searched for articles on handover improvement interventions in EMBASE, MEDLINE, HMIC and CINAHL between January 2002 and July 2012. We considered studies of: staff knowledge and skills, staff behavioural change, process change or patient outcomes.

RESULTS

631 potentially relevant papers were identified from which 29 papers were selected for inclusion (two randomised controlled trials and 27 uncontrolled studies). Most studies addressed shift-change handover and used a median of three outcome measures, but there was no outcome measure common to all. Poor study design and inconsistent reporting methods made it difficult to reach definite conclusions. Information transfer was improved in most relevant studies, while clinical outcome improvement was reported in only two of 10 studies. No difference was noted in the likelihood of success across four types of intervention.

CONCLUSIONS

The current literature does not confirm that any methodology reliably improves the outcomes of clinical handover, although information transfer may be increased. Better study designs and consistency of the terminology used to describe handover and its improvement are urgently required.

Exploring perinatal shift-to-shift handover communication and process: an observational study

RATIONALE, AIMS AND OBJECTIVES

Loss of situation awareness (SA) by health professionals during handover is a major threat to patient safety in perinatal care. SA refers to knowing what is going on around. Adequate handover communication and process may support situation assessment, a precursor of SA. This study describes current practices and opinions of perinatal handover to identify potential improvements.

METHODS

Structured direct observations of shift-to-shift patient handovers (n = 70) in an academic perinatal setting were used to measure handover communication (presence and order of levels of SA: current situation, background, assessment and recommendation) and process (duration, interruptions/distractions, eye contact, active inquiry and reading information back). Afterwards, receivers' opinions of handover communication (n = 51) were measured by means of a questionnaire.

RESULTS

All levels of SA were present in 7% of handovers, the current situation in 86%, the background in 99%, an assessment in 24% and a recommendation in 46%. In 77% of handovers the background was mentioned first, followed by the current situation. Forty-four per cent of handovers took 2 minutes or more per patient. In 52% distractions occurred, in 43% there was no active inquiry, in 32% no eye contact and in 97% information was not read back. The overall mean of the receivers' opinions of handover communication was 4.1 (standard deviation ± 0.7; scale 1-5, where 5 is excellent).

CONCLUSIONS

Perinatal handovers are currently at risk for inadequate situation assessment because of variability and limitations in handover communication and process. However, receivers' opinions of handover communication were very positive, indicating a lack of awareness of patient safety threats during handover. Therefore, the staff's awareness of current limitations should be raised, for example through video reflection or simulation training.

Fragmentation of patient safety research: a critical reflection of current human factors approaches to patient handover

The integration of human factors science in research and interventions aimed at increased patient safety has led to considerable improvements. However, some challenges to patient safety persist and may require human factors experts to critically reflect upon their predominant approaches to research and improvement. This paper is a call to start a discussion of these issues in the area of patient handover. Briefly reviewing recent handover research shows that while these studies have provided valuable insights into the communication practices for a range of handover situations, the predominant research strategy of studying isolated handover episodes replicates the very problem of fragmentation of care that the studies aim to overcome. Thus, there seems to be a need for a patient-centred approach to handover research that aims to investigate the interdependencies of handover episodes during a series of transitions occurring along the care path. Such an approach may contribute to novel insights and help to increase the effectiveness and sustainability of interventions to improve handover. Significance for public healthWhile much of public health research has a preventive focus, health services research is generally concerned with the ways in which care is provided to those requiring treatment. This paper calls for a patient-centred approach to research on patient handover; a significant contributor to adverse events in healthcare. It is argued that this approach has the potential to improve our understanding of handover processes along the continuum of care. Thus, it can provide a scientific foundation for effective improvements in handover that are likely to reduce patient harm and help to maintain patient safety.