The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department

A scoping review of clinical handover mnemonic devices

Since the Institute of Medicine (IOM) published To Err is Human: Building a Safer Health System in 1999, clinical handovers (or handoffs) and their relationship with the communication of patient safety have raised concerns from the public, regulatory bodies, and medical practitioners. Protocols, guidelines, forms, and mnemonic devices have been created to ensure safer clinical handovers. An initial literature search did not find a framework to describe the clinical processes and functions of each mnemonic device and its elements. The absence of a systematic framework could hinder the study across and the reusability of the established clinical handover mnemonic devices. This study aims to develop a universal framework to describe the clinical processes and functions essential for patient safety during handover. We queried PubMed.gov and obtained 98 articles related to clinical handovers. We examined the citing sources of the mnemonics mentioned in these articles. A total of 42 handover mnemonics with 238 elements were identified. Our review noted that there was no taxonomy to describe the clinical functions and process associated with the clinical handover mnemonic devices. We used grounded theory to address this gap and built a new taxonomy from the 42 mnemonics. A researcher read all mnemonics, developed a taxonomy for tagging clinical handover mnemonics, and categorized all mnemonic elements into correct processes and functions. After that, the second researcher, a medical practitioner, examined the taxonomy and made suggested corrections for the labelled functions of all mnemonic elements. Both researchers agreed on the taxonomy and the labelled processes and functions of different mnemonic elements. The taxonomy contains three processes and twenty functions in clinical handovers. Clinical processes like 'medical condition', 'medical history', 'medical evaluation', 'care plan', 'outstanding care/tasks/results', and 'patient information', as an administrative process, were widely adopted in clinical handover mnemonics. Moreover, mnemonic elements on communication manner and information validation had been identified in the list of clinical handover mnemonics. Although we recognize challenges because of both the vast number of clinical handover scenarios and the task of placing them under a few predefined groups, our findings suggest that such a taxonomy, as developed for this study, could assist medical practitioners to devise a clinical handover mnemonic to best fit their workplace.

Clinical handover communication at maternity shift changes and women's safety in Banjul, the Gambia: a mixed-methods study

Background

Clinical handover is a vital communication process for patient safety; transferring patient responsibility between healthcare professionals (HCPs). Exploring handover processes in maternity care is fundamental for service quality, addressing continuity of care and maternal mortality.

Methods

This mixed-methods study was conducted in all three maternity hospitals in Banjul, The Gambia. Shift-to-shift maternity handovers were observed and compared against a standard investigating content and environment. Semi-structured interviews and focus group discussions with doctors, midwives and nurses explored handover experience.

Results

One hundred ten nurse/midwife shift-to-shift handovers were observed across all shift times and maternity wards; only 666 of 845 women (79%) were handed over. Doctors had no scheduled handover. Shift-leads alone gave/received handover, delayed [median 35 min, IQR 24–45] 82% of the time; 96% of handovers were not confidential and 29% were disrupted. Standardised guidelines and training were lacking.

A median 6 of 28 topics [IQR 5–9] were communicated per woman. Information varied significantly by time, high-risk classification and location. For women in labour, 10 [IQR 8–14] items were handed-over, 8 [IQR 5–11] for women classed ‘high-risk’, 5 [IQR 4–7] for ante/postnatal women (p < 0.001); > 50% had no care management plan communicated.

Twenty-one interviews and two focus groups were conducted. Facilitators and barriers to effective handover surrounding three health service factors emerged; health systems (e.g. absence of formalised handover training), organisation culture (e.g. absence of multidisciplinary team handover) and individual clinician factors (e.g. practical barriers such as transportation difficulties in getting to work).

Conclusion

Maternity handover was inconsistent, hindered by contextual barriers including lack of team communication and guidelines, delays, with some women omitted entirely. Findings alongside HCPs views demonstrate feasible opportunities for enhancing handover, thereby improving women's safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05052-9.

Improving the Medical and Surgical Out-of-Hours Handover at a Hospital in Regional New South Wales, Australia

Introduction: Effective handover between shifts is widely accepted as essential for continuity of care and patient safety. Problems with out-of-hours handover were identified at our hospital, having come to light following attendance at handover meetings by the authors.

Methods: Consultation of junior doctors was performed to identify issues with the out-of-hours handover and a baseline audit was conducted to objectively assess handover practice. Local guidelines were used to create a handover tool, which was subsequently implemented and assessed via multiple PDSA (plan, do, study, and act) cycles. In addition, registrar education was undertaken. Concurrently, meetings with senior clinicians and managers were held to address wider issues including venue, intensive care registrar attendance, emergency call procedures, and implementation of an electronic handover tool.

Results: Junior doctor consultation and baseline audit identified failings in handover. Following our intervention, improvements were demonstrated in the handover of patient information, including diagnosis (50% increase), investigations (76% increase), and plan (33% increase). Doctor attendance and punctuality also improved, along with a more punctual start time and reduced handover duration of five minutes on average.

Conclusion: Bringing structure and leadership to an informal and inconsistent handover system using simple and well-defined methods can improve the quality and consistency of handover. The sustainability of the intervention was demonstrated with continued improvements seen in a subsequent cycle.

Obstetric shift-to-shift handover in Kerala, India: A cross-sectional mixed method study

INTRODUCTION

Beyond the provision of services, quality of care and patient safety measures such as optimal clinical handover at shift changes determine maternity outcomes. We aimed to establish the proportion of women handed over and the content of clinical handovers and communication between shifts within 3 diverse obstetrics units in Kerala, India, and to describe the handover environment.

METHODS

A cross sectional study was conducted for six weeks during February and March 2015at three hospitals in Kerala, India, during nurses obstetric handover in one tertiary private, one tertiary government and one secondary government hospital. Nursing handovers in obstetric post-operative, in-patient and labour wards were sampled. An SBAR-based (situation, background, assessment and recommendation) data schedule was completed whilst observing handover at nursing shift changes. Since obstetricians had no scheduled handover, qualitative interviews were conducted with obstetricians in two hospitals to establish how they acquire information when beginning a shift.

RESULTS

Data was obtained on 258 patients handed over, within 67 shift changes. The median percentage of women handed over was 100% in two of the hospitals and 27.6% in the other. The median number of information items included out of a possible 25 was 11, 5 and 4,and did not change significantly for women with high-risk status. Important items regarding assessment and recommendation for care were often missed, including high-risk status. The median number of environment items achieved was good at 7 out of 10 in all hospitals. Obstetricians sought information in various ways when required. All supported the development of structured tools, face-to-face and team handovers.

CONCLUSIONS

Maternity unit handovers for doctors and nurses were inadequate. Ensuring handover of all women and including critical information, between shifts as well as between doctors, needs to be improved to increase patient safety.

Evaluation of emergency service nurses' patient handover and affecting factors: A descriptive study

AIM

The aim of the study was to determine the patient handover efficacy level of emergency room nurses and the influencing factors.

METHOD

This descriptive, cross-sectional study was completed with (n = 120) emergency room nurses of two different state hospitals from April 26 to May 26, 2021. The "Nurses descriptive information form" and "Handover Evaluation Scale" were used as data collection forms.

RESULTS

The mean age of the nurses was 29.53(6.327 years, 70.8% of them were female, and 76.7% of them had a bachelor's degree. The mean number of handovers was 3.25 (SD = 3.17) for one nurse in a shift, and the mean handover duration for a patient was 10.16 (SD = 9.23) minutes. More than half of the nurses (61.7%) carried out oral handover at the bedside. The mean score of the handover evaluation scale was 53.31 (SD = 9.55). The mean score of the nurses who performed the handover with all the nurses on the shift (spelling and relieving) together was 56.47 (SD = 9.21) and higher than that of the nurses who performed the handover in small groups 49.84 (SD = 9.70), (p = 0.012).

CONCLUSION

The results of this study may contribute to promoting patient safety and improving patient handover processes in emergency rooms. It is recommended that standardized and comprehensive written handover forms be used, that all emergency room nurses should attend the handover process, and that further observational and interventional studies should be conducted.

[Safer anesthesia and duty hour limits: are handovers of personnel allowed?]

Restrictions of duty hours in medicine are an ambivalent matter with respect to patient safety. Continuity of treatment carries the risk of medical errors from declining performance capability and must be balanced against the risk of communication failure and information loss due to personnel changes. Complete intraoperative changes of anesthetists are frequently carried out in the clinical routine but possibly have the potential to negatively influence the postoperative morbidity and mortality. The relevance of anesthesiological care for the perioperative outcome also seems to vary depending on the specialist discipline involved. While standardized handover protocols seem to be only of limited effectiveness for the improvement of transfer of information, they are nevertheless a reasonable approach for optimization of interprofessional communication and reduction of treatment errors.

Communication between pre-hospital and intra-hospital emergency medical services: literature review

OBJECTIVES

to analyze, according to the scientific literature, communication strategies in the transfer of cases between pre-hospital and in-hospital services and their contributions to patient safety.

METHODS

this is a literature review study, that is, one that aims to gather and synthesize research results on the subject in a systematic and orderly manner.

RESULTS

ten articles were published, published between 2010 and 2018, and two points of discussion emerged: use of mnemonics; and barriers to transferring a case.

CONCLUSIONS

studies point to the need to standardize the case transfer process, as well as integrative training of professionals, regular assessment of the teams involved in emergency medical services and the need for research on the subject.

Assessment and improvement of junior doctor handover in the emergency department

Introduction

Effective handover between junior doctors is widely accepted as essential for patient safety. The British Medical Association in association with the National Health Service (NHS) National Patient Safety Agency and NHS Modernisation Agency have produced clear guidance regarding the contents and setting for a safe and efficient handover. We aimed to understand current junior doctor’s opinions on the handover process in a London emergency department (ED), with subsequent assessment, and any necessary improvement, of handover practices within the department.

Methods

In a London ED, a baseline survey was completed by the senior house officer (SHO) cohort to gauge current opinions of the existing handover process. Concurrently, a blinded prospective audit of handover practises was conducted. Multiple improvement strategies were subsequently implemented and assessed via Plan–Do–Study–Act (PDSA) cycles. A standard operating procedure was initially introduced and ‘rolled out’ throughout the department. This intervention was followed by development of an electronic handover note to ease completion of a satisfactory handover. Additional surveys were conducted to continually assess SHO opinion on how the handover process was developing. The final improvement strategy was formal handover teaching at the SHO induction.

Results

Baseline audit and SHO survey highlighted several opportunities for improvement. 5 handover components were deemed essential: (1) documented handover note; (2) doctor’s names; (3) history of presenting complaint; (4) ED actions; and (5) ongoing plan. The frequency of these components saw significant improvement by completion of the final PDSA. Following SHO rotation, all of the essential components fell, only to recover after the next improvement strategy.

Conclusions

Junior doctors in a London ED were not satisfied with the current SHO handover process, and handover practices were not adequate. While the rotational nature of the SHO cohort makes sustained change challenging, implementation of thoughtful and realistic improvement strategies can significantly improve handover quality.

The critical care nurse's perception of handover: A phenomenographic study

OBJECTIVE

To describe variations in critical care nurses' perceptions of handover.

RESEARCH METHODOLOGY

Phenomenographic design using individual interviews for data-collection.

SETTING

The critical care nurses participating in the study were recruited from critical care units in three hospitals in Sweden.

FINDINGS

Five descriptive categories were identified: Communication between staff, Opportunity for learning, Patient-centred information gathering as a basis for continuous care, Responsibility for transfers, and Patient safety and quality of care.

CONCLUSION

Nursing handover is a complex phenomenon, which is understood in various ways. Handover is mediated through communication and marks a shift in responsibility. Handover seems to be related to patient safety and quality of care. There is potential for improvement in the quality of nursing handover in clinical praxis, but further research is needed to determine ways of improving quality of handover.

Development and implementation of a standardised emergency department intershift handover tool to improve physician communication

BACKGROUND

Structured handover can reduce communication breakdowns and potential medical errors. In our emergency department (ED) we identified a safety risk due to variation in quality and content of overnight handovers between physicians.

AIM

Our goal was to develop and implement a standardised ED-specific handover tool using quality improvement (QI) methodology. We aimed to increase the proportion of patients having adequate handover information conveyed at overnight shift change from a baseline of 50%-75% in 4 months.

METHODS

We used published best practices, stakeholder input and local data to develop a tool customised for intershift ED handovers. Implementation methods included education, cognitive aids, policy change and plan-do-study-act cycles informed by end-user feedback. We monitored progress using direct observation convenience sampling.

MEASURES

Our outcome measure was proportion of adequate patient handovers (defined as >50% of handover components communicated per patient) per overnight handover session. Tool utilisation characteristics were used for process measurement, and time metrics for balancing measures. We report changes using statistical process control charts and descriptive statistics.

RESULTS

We observed 49 overnight handover sessions from 2017 to 2019, evaluating handovers of 850 patients. Our improvement target was met in 10 months (median=76.1%) and proportion of adequate handovers continued to improve to median=83.0% at the postimprovement audit. Written communication of handover information increased from a median of 19.2% to 68.7%. Handover time increased by median=31 s per patient. End-users subjectively reported improved communication quality and value for resident education.

CONCLUSIONS

We achieved sustained improvements in the amount of information communicated during physician ED handovers using established QI methodologies. Engaging stakeholders in handover tool customisation for local context was an important success factor. We believe this approach can be easily adopted by any ED.

Developing an emergency medicine handoff tool: an electronic Delphi approach

BACKGROUND

Handoffs at the end of clinical shifts occur with high frequencies in the emergency department setting and they pose an increased risk to patients. There is a need to standardize handoff practices. This study aimed to use an electronic Delphi method to identify the core elements essential for an emergency department physician to physician handoff and propose a framework for implementation.

METHODS

An electronic Delphi-style study with a national panel of board-certified emergency physicians in Saudi Arabia. The panel was conducted over four rounds. The first to identify elements relevant to the end of shift handoff and categorize them into domains, while the remaining three to score and debate individual elements.

RESULTS

Twenty-five board-certified emergency physicians from various cities and practice settings were enrolled. All panelists completed the entire Delphi process. Thirty-two elements were identified and classified into 4 domains. The top five rated handoff elements were patient identification, chief complaint history, clinical stability, working diagnosis, and consulting services involved. Panel scores showed convergence as rounds progressed and the final list of elements had a high-reliability score (Cronbach's alpha 0.93).

CONCLUSIONS

This study yielded an itemized and ranked list of elements that are easy to implement and could be used to standardize patient handoffs by emergency physicians. While this study was conducted on an emergency medicine panel, the methods used may be adapted to develop standardized handoff frameworks that serve different disciplines or practice settings.

The handover room: a qualitative enquiry into the experience of morning clinical handover for acute medical teams

BACKGROUND

Effective clinical handover has always been integral to delivering safe, high-quality care in medical wards.

AIM

As handover activity increases in importance we wanted to explore the experience of physicians and trainee doctors. There is little research on internal medicine handover with even less based on direct observational research.

METHODS

Data collection over 4 months by two general medicine physicians included participant observation of 37 meetings and 52 audio-recorded individual interviews. Inductive thematic analysis of the transcribed interviews proceeded iteratively in parallel with data collection.

RESULTS

There was an excellent response rate from 27 of 28 invited trainees and 25 of 26 invited physicians. Overall the experience was positive. Acute medicine handover is a complex human endeavour, occurring daily with an unpredictable workload and areas of tension. Themes were grouped as structural (leadership role, start time, sequence, checklist, handbacks and efficiency) and relational (sensitivity, collegiality, acknowledgement, performance anxiety, tension, responsibility and leadership style). The physician leader needs to be skilled to follow the agreed and evolving process as well as being prepared, authoritative, flexible, equitable, aware and sensitive to the needs of senior colleagues and trainees. There was a tension between efficiency and teaching opportunities.

CONCLUSION

This paper adds to a contextually sensitive understanding of the social dynamics of handover in acute medicine. Addressing the structural aspects is important to provide the necessary consistency and efficiency in what is an extremely complex and time-sensitive environment. As we continue to work on the evolution of the handover process in acute internal medicine, we must also attend to the relational aspects which are dynamic and central to its sustainability.

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.

Standardized Reporting System Use During Handoffs Reduces Patient Length of Stay in the Emergency Department

Background

Emergency department (ED) shift handoffs are potential sources of delay in care. We aimed to determine the impact that using standardized reporting tool and process may have on throughput metrics for patients undergoing a transition of care at shift change.

Methods

We performed a prospective, pre- and post-intervention quality improvement study from September 1 to November 30, 2015. A handoff procedure intervention, including a mandatory workshop and personnel training on a standard reporting system template, was implemented. The primary endpoint was patient length of stay (LOS). A comparative analysis of differences between patient LOS and various handoff communication methods were assessed pre- and post-intervention. Communication methods were entered a multivariable logistic regression model independently as risk factors for patient LOS.

Results

The final analysis included 1,006 patients, with 327 comprising the pre-intervention and 679 comprising the post-intervention populations. Bedside rounding occurred 45% of the time without a standard reporting during pre-intervention and increased to 85% of the time with the use of a standard reporting system in the post-intervention period (P < 0.001). Provider time (provider-initiated care to patient care completed) in the pre-intervention period averaged 297 min, but decreased to 265 min in the post-intervention period (P < 0.001). After adjusting for other communication methods, the use of a standard reporting system during handoff was associated with shortened ED LOS (OR = 0.60, 95% CI 0.40 - 0.90, P < 0.05).

Conclusions

Standard reporting system use during emergency physician handoffs at shift change improves ED throughput efficiency and is associated with shorter ED LOS.

Improving handover between the transport team and neonatal intensive care unit staff in neonatal transports using the plan-do-study-act tool

OBJECTIVES

The aim was to achieve 100% effective handover from the critical care transport team to the neonatal intensive care unit (NICU) medical team.

STUDY DESIGN

All patients transferred from referring hospitals by the critical care transport team to the Level IV NICU were included. Data for each infant was collected prospectively. The percentage of transported patients for which medical team and nursing handover occurred was recorded. A quality improvement project was launched using the Plan-Do-Study-Act (PDSA) tool. We implemented several processes including call from the transport team before arrival and the completion of a transfer of care form on arrival to the NICU. The process measures and the outcome measure of completion of handover were monitored. Run charts of process measures and the outcome measure were analyzed.

RESULTS

Completion of medical handover increased from 95% (baseline) to 100% after 3 PDSA cycles and this has been maintained for 18 consecutive months.

CONCLUSION

Medical handover from the critical care transport team to the NICU medical staff has been achieved and sustained for all neonatal transports.

Introduction of the identification, situation, background, assessment, recommendations tool to improve the quality of information transfer during medical handover in intensive care

OBJECTIVE

To audit the quality and safety of the current doctor-to-doctor handover of patient information in our Cardiothoracic Intensive Care Unit. If deficient, to implement a validated handover tool to improve the quality of the handover process.

METHODS

In Cycle 1 we observed the verbal handover and reviewed the written handover information transferred for 50 consecutive patients in St George's Hospital Cardiothoracic Intensive Care Unit. For each patient's handover, we assessed whether each section of the Identification, Situation, Background, Assessment, Recommendations tool was used on a scale of 0-2. Zero if no information in that category was transferred, one if the information was partially transferred and two if all relevant information was transferred. Each patient's handover received a score from 0 to 10 and thus, each cycle a total score of 0-500. Following the implementation of the Identification, Situation, Background, Assessment, Recommendations handover tool in our Intensive Care Unit in Cycle 2, we re-observed the handover process for another 50 consecutive patients hence, completing the audit cycle.

RESULTS

There was a significant difference between the total scores from Cycle 1 and 2 (263/500 versus 457/500, p < 0.001). The median handover score for Cycle 1 was 5/10 (interquartile range 4-6). The median handover score for Cycle 2 was 9/10 (interquartile range 9-10). Patient handover scores increased significantly between Cycle 1 and 2, U = 13.5, p < 0.001.

CONCLUSIONS

The introduction of a standardised handover template (Identification, Situation, Background, Assessment, Recommendations tool) has improved the quality and safety of the doctor-to-doctor handover of patient information in our Intensive Care Unit.

Impact of an education session on clinical handover between medical shifts in an emergency department: A pilot study

OBJECTIVE

To evaluate the impact of a medical education session on the implementation of a new change of shift medical clinical handover format in an urban hospital ED.

METHODS

This pilot study used a pre- and post-intervention design. The intervention consisted of a 1 h education session to teach a new handover format, SBARM (Situation, Background, Assessment, Recommendation, Medication). Data were collected through observations of doctors performing clinical handover and individual interviews with participants.

RESULTS

The educational intervention led to an increased focus on checking medication charts, but had minimal effect on changing other aspects of clinical handover at doctors' change of shift times. Perceived increased time spent on handover using the new system was seen as a major barrier to the implementation of SBARM. The addition of 'M' to 'SBAR' heightened awareness of checking medication and fluid charts.

CONCLUSION

Time pressures need to be taken into consideration when introducing changes to current processes. Also, it is recommended that, in addition to ongoing education, senior clinicians are engaged during the planning and execution stages of changes to practice.

Quality in paediatric emergency medicine: Measurement and reporting

There is a clear demand for quality in the delivery of health care around the world; paediatric emergency medicine is no exception to this movement. It has been identified that gaps exist in the quality of acute care provided to children. Regulatory bodies in Australia and New Zealand are moving to mandate the implementation of quality targets and measures. Within the paediatric emergency department (ED), there is a lack of research into paediatric specific indicators. The existing literature regarding paediatric acute care quality measures has been recently summarised, and expert consensus has now been reported. It is clear that there is much work to be performed to generalise this work to ED. We review suggestions from the current literature relating to feasible indicators within the paediatric acute care setting. We propose options to develop a quality 'scorecard' that could be used to assist Australian and New Zealand EDs with quality measurement and benchmarking for their paediatric patients.

Improving Continuity of Care via the Discharge Summary

Discharge summaries (DCS) frequently fail to improve the continuity of care. A chart review of 188 DCS was performed to identify specific components that could be improved through health information technology. Medication reconciliations were analyzed for completeness and for medical reasoning. Documentation of pending results and follow-up details were analyzed. Patient preferences, patient goals, and the handover tone were noted. Patients were discharged on an average of 9.8 medications, only 3% of medication reconciliations were complete and medical reasoning was frequently absent. There were 358 pending results in 188 hospital discharges though only 14% were mentioned in the DCS. Documentation of clear, timely follow-up was present for less than 50% of patients. Patient preferences, patient goals, and lessons learned were rarely included. A handover tone was in only 17% of the DCS. Evaluating the DCS as a clinical handover is novel but information for safe handovers is frequently missing.

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Background

Hospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.

Objectives

This study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.

Design

We used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.

Setting

Welsh Government and NHS Wales.

Participants

Interviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.

Main outcome measures

Identification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.

Results

An innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.

Conclusions

Heightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A novel briefing checklist at shift handoff in an emergency department improves situational awareness and safety event identification

OBJECTIVES

Emergency department (ED) shift handoffs are sources of potential medical error, delays in care, and medicolegal liabilities. Few handoff studies exist in the ED literature. We aimed to describe the implementation of a standardized checklist for improving situational awareness during physician handoffs in a pediatric ED.

METHODS

This is a descriptive observational study in a large academic pediatric ED. Checklists were evaluated for rates of use, completion, and identification of potential safety events. We defined a complete checklist as 80% or more of items checked.  A user perception survey was used. After 1 year, all checklist users (residents, fellows, faculty, and charge nurses with ED experience before and after checklist implementation) were anonymously surveyed to assess the checklist's usability, perceived contributions to Institute of Medicine quality domains, and situational awareness. The electronically administered survey used Likert frequency scales.

RESULTS

Of 732 handoffs, 98% used the checklist, and 89% were complete. A mean of 1.7 potential safety events were identified per handoff. The most frequent potential safety events were identification of intensive care unit-level patients in the ED (48%), equipment problems (46%), staffing issues (21%), and intensive care unit-level patients in transport (16%). Eighty-one subjects (88%) responded to the survey. The users agreed that the checklist promoted better communication, safety, efficiency, effective care, and situational awareness.

CONCLUSIONS

The Physician Active Shift Signout in the Emergency Department briefing checklist was used often and at a high completion rate, frequently identifying potential safety events. The users found that it improved the quality of care and team communication. Future studies on outcomes and processes are needed.

Communication of Vital Signs at Emergency Department Handoff: Opportunities for Improvement

STUDY OBJECTIVE

We describe the prevalence of vital sign communication errors during emergency department (ED) handoffs. Our secondary objective is to evaluate the association between handoff behaviors and ED crowding on vital sign handoff errors.

METHODS

This was a prospective observational study of ED handoffs conducted at an urban academic hospital. We observed a prespecified convenience sample of ED shift rounds and included all patients whose care was subject to a handoff during ED shift change. The primary outcome was vital sign communication errors, defined as the failure to communicate an episode of medical-record-documented hypotension or hypoxia during ED shift rounds. Trained research assistants used a standardized data collection tool to collect data through direct observation and electronic health record abstraction. We report descriptive statistics and results of a logistic regression model constructed with generalized estimating equations to describe the association between handoff and rounds-level characteristics and handoff errors.

RESULTS

We observed 1,163 patient handoffs during 130 ED shift rounds. Of 117 patients with episodes of hypotension and 156 patients with hypoxia, 66 (42%) and 116 (74%) were not communicated at rounds, respectively. One hundred sixty-six handoffs (14%) included a vital sign communication error of omission. In multivariate analysis, no handoff or rounds characteristic, including the ED occupancy rate, was associated with omission errors of vital sign communication.

CONCLUSION

Providers omitted communication of patient hypotension or hypoxia in nearly 1 in 7 ED handoffs. These communication errors do not appear to be related to ED crowding or care interruptions.