human factors and clinical change -...
TRANSCRIPT
Human Factors in Clinical
Handovers
Dr Ken Catchpole
Director of Surgical Safety and Human Factors Research
Cedars Sinai Medical Center
Los Angeles
Reinforce and expand knowledge about
handovers
What is “Human Factors”?
What is a handover?
What goes wrong in handover?
What can we do about it?
Aim
What do I do?
HUMAN FACTORS or ERGONOMICS
The science of:
What people do well
Why they do it well
What people do NOT do well
Why they do NOT do it well
Humans in Complex Systems
Humans: are a fundamental component of ANY system
are uniquely able to function in uncertainty, and make trade-offs
create safety in complex systems
Complex systems: are inherently unsafe
always function at the limits of capacity
require safety to be traded for other aspects of system performance.
“Human Error is the inevitable by-product of the pursuit of success in an imperfect, unstable, resource constrained world.” (Dekker, 2003)
Technology
People
Organisation Environment
Tasks
Carayon et al. Qual.Saf Health Care 2006, 15 Suppl 1:i50-i58.
Systemic influences on HUMAN performance
“HUMAN FACTORS”
Task standardization Roles & Rules
Prediction & planing
Selection Training
Assessment
Safety Culture Resilience
Learning from Accidents
Workspace Design Geographical distribution
Physical Constraints
Design Procurement Integration
Human Factors in Design
High Control Compatibility Low Control Compatibility
Enhancing clinical performance through an
understanding of the effects of teamwork, tasks,
equipment, workspace, culture, and organisation
on human behaviour and abilities, and the
application of that knowledge in clinical settings.
www.chfg.org
What is ‘Clinical Human Factors’?
WHAT IS A HANDOVER?
Human Factors in Clinical Handovers
Handover Classification System (Cohen & Hilligoss, 2010)
between-unit transfer of a new patient
within-unit continuing patient transfer
within-unit new patient transfer
within-unit temporary role assumption transfer
Handoff Types
Handover Conceptualised
Team 1 Team 2
Han
dover
Principle Components of Handover
“Information Transfer”
“Shared Understanding”
“Working Atmosphere”
Manser et al. 2010
Skills
Protocols and Procedures
Technology and Tools
Environment and Organisation
Handover Conceptualised
Team 1 Team 2
Han
dover
Skills
Protocols and Procedures
Technology and Tools
Environment and Organisation
Handover as a Dynamic Process
Team 1 Team 2
Han
dover
Information & situation constantly changing
Building picture
TAKE control
Summarising picture
GIVE control
What about more complex
handovers?
Jane Carthey, 2011
Hospital at Night
Handover
H@N Handover Medical & nursing
handover
AM ward rounds
PM ward rounds
Evening Short day Long day Nursing
handover
New events •Theatre
•Admissions •2222 •PICU
Discharge
CSP Site security
staffing handover
H@N
Huddles
“Ecosystem” of multiple
handovers
Information Transmission /
Deviations from normal /
Revealing Problems /
Transfer of Responsibility /
Networked knowledge /
Reinforcing values /
‘Framing’ of handovers
- Patterson & Wears 2010, The Joint Commission Journal on Quality and Patient Safety 36(2)
Increasing Interest
PubMed Publications on “Handover” PubMed Publications on “Handoff”
Gaps in current understanding
“…rarely consider the dynamic nature…”
“…narrow definition of handover as information transfer….”
“….focus on standardisation….”
“….discrepancy between objective assessment and satisfaction….”
“…lack of systematic research…and adequate measures of effectiveness….”
Manser (2011). Minding the gaps: moving handover research forward. European
Journal of Anaesthesiology, 28: 613-615
Handoff Incidents
Thomas MJ, J Schultz T, Hannaford N, Runciman WB. Failures in Transition: Learning from Incidents Relating to Clinical Handover in Acute Care. J Healthc Qual. 2012 Jan 23. doi: 10.1111/j.1945-1474.2011.00189.x.
In 458 incidents the most prevalent failure types: transfer of patients without adequate handover 28.8% (n = 132)
omissions of critical information about the patient's condition 19.2% (n = 88)
Omissions of critical information about the patient's care plan during the handover process 14.2% (n = 65).
The most prevalent failure detection mechanisms: expectation mismatch 35.7% (n = 174)
clinical mismatch 26.9% (n = 127)
mismatch with other documentation 24.0% (n = 117).
ICU Nurse
1
Consultant
Anaesthetist 1 Consultant
Anaesthetist 2
SEU Nurse
2
Recovery
Nurse 1
SEU Nurse
1
Recovery
Nurse 2 ICU
Nurse 2 Theatre
Nurse 2
Theatre
Nurse 1
Historical working
practice
Known problems Unaware of Processes
Poor
Communication
Poor
Coordination
Lack of
Consistency
Time
Issues
Quality &
safety
“Of course, there is a process ……..but
everyone does it differently”
Catchpole et al. (2010). Patient transfers within the hospital: translating knowledge from motor
racing to healthcare. Quality and Safety in Healthcare 19, pp. 318-322.
Skills
Protocols and Procedures
Technology and Tools
Environment and Organisation
Handover as a Dynamic Process
Team 1 Team 2
Han
dover
Information & situation constantly changing
Building picture
TAKE control
Summarising picture
GIVE control
Checking Processes
Establish Currency
Monitor Changes
Skills
Protocols and Procedures
Technology and Tools
Environment and Organisation
Handover as a Dynamic Process
Team 1 Team 2
Information & situation constantly changing
Han
dover
Control Overlap
Building picture
TAKE control
Summarising picture
GIVE control
Skills
Protocols and Procedures
Technology and Tools
Environment and Organisation
Handover as a Dynamic Process
Team 1 Team 2
Han
dover
Information & situation constantly changing
Building picture
TAKE control
Summarising picture
GIVE control
Technologies
Surgery to ICU
“…the transfer from the operating
theatre to the intensive care unit is one
of the most difficult stages in the care
of a child.” - p. 214, Learning from Bristol (2001)
TANSFER OF:
- safety-critical monitoring & support equipment from theatre to ICU
- patient care, information & plans from operating team to intensive care team
NOTE
F1 Video
Multiple specialists
Complex tasks
Complex interfaces
Time pressure
Need for accuracy
Process Organisation
– Task Allocation
– Task sequence
– Discipline and composure
Teamwork
– Leadership
– Involvement
– Briefing
Threat and Error Management
– Checklists
– Predicting and Planning
– Situation Awareness
Technology
Training Regimes
Lessons from F1 and Aviation
“It’s fine as it is”
“We’ve always done it like this”
“We don’t have time to do it like this”
“It might make things worse”
“But so many other things are wrong”
“We’re different here”
Resistance to Change
28
Identify the problem Break it down
Generate multiple solutions
Involve everyone Be visible
Obtain support and establish “Champions”
Use the most negative people
Don’t listen to “No”
Make the change Gather evidence
Plan, Do, Check, Act
Making Change
Overview of the New Process
Prior to
Transfer
Patient Transfer Sheet
obtained from theatre
Bedspace & equipment
prepared in CCC
Technology
Transfer
Equipment is
configured in CCC
SAFETY CHECK
Information
Handover
Anaesthetist then
Surgeon hand over
information using
Information Transfer
Aide Memoir
SAFETY CHECK
Discussion &
Plan
Group discussion
Anticipation of
problems
Immediate care
strategy agreed
Training time = 30 minutes
Errors in BOTH Equipment AND Information:
BEFORE AFTER
>1 in both 39% 11%
>4 in both 13% 4%
Correlation r=0.513 r=0.262
p<0.01 p=0.186
Compounding Errors
Team Performance
0
1
2
3
4
5
6
7
8
9
10
5 7 9 11 13 15 17 19
Team performance /20
Nu
mb
er
of
Err
ors
/1
6
Pre-Intervention
Post-Intervention
Pre (Predicted)
Post (Predicted)
Ineffective Effective
Good
Poor
Nu
mb
er
of
Err
ors
“This is great….
……but we can make it better” Consultant Anaesthetist, February 2007
Acceptance of Change
Continuous Improvement
High Reliability
Some useful rules of thumb
Avoid notions of blame; understand motivations
Trying harder will not work (& “should” is dangerous)
Good outcome ≠ good process
Is it easy to do right and hard to do wrong?
Do we know what “right” looks like?
Thank you for listening
Dr Ken Catchpole
Cedars-Sinai Medical Centre
Los Angeles
http://www.safersurgery.co.uk
Catchpole K (2011). Task, Team and Technology Integration in the Paediatric Cardiac Operating Room. Progress in Pediatric Cardiology 32
(2), 85-88.
Catchpole, K, Dale, T, Hirst, G, Smith, P, Giddings, A.(2010). A multi-centre trial of aviation-style training for surgical teams. Journal of
Patient Safety. 6(3), pp. 180-186.
Catchpole, K, Sellers, R, Goldman, A, McCulloch, P, Hignett, S (2010). Patient transfers within the hospital: translating knowledge from
motor racing to healthcare. Quality and Safety in Healthcare 19, pp. 318-322.
McCulloch, P, Mishra, A, Handa, A, Dale, T, Hirst, G, Catchpole, K. (2009). The effects of Aviation-style non-technical skills training on
technical performance and outcome in the operating theatre. Quality and Safety in Healthcare 18, pp. 109-115.
Catchpole, K (2009). Commentary: Who do we blame when it all goes wrong? Quality and Safety in Healthcare 17(1), pp.4-5.
Catchpole, K, Bell, D, Johnson, S (2008). Safety in Anaesthesia: A study of 12606 reported incidents from the UK National Reporting and
Learning System. Anaesthesia 63, pp. 340-346.
Catchpole, K, Mishra, A, Handa, A, McCulloch, P (2008). Teamwork and Error in the Operating Room: Analysis of Skills and Roles. Annals
of Surgery 247(4), pp.699-706.
Catchpole, K, Giddings, A, Wilkinson, M, Hirst, G, Dale, T, De Leval, M. (2007) Improving patient safety by identifying latent failures in
successful operations. Surgery 142(1), pp.102-110.
Catchpole, K, de Leval, M, McEwan, A, Pigott, N, Elliott, M, McQuillan, A, MacDonald, C, Goldman, A (2007). Patient Handover from
Surgery to Intensive Care: Using Formula 1 and Aviation Models to Improve Safety and Quality. Pediatric Anesthesia 17(5), pp. 470-478.
Catchpole, K, Giddings, A, De Leval, M, Peek, G, Godden, P, Utley, M, Gallivan, S, Hirst, G, Dale, T (2006). Identification of systems failures
in successful paediatric cardiac surgery. Ergonomics 49(5-6), pp.567-588.
Selected Publications