human factors and clinical change -...

Human Factors in Clinical

Handovers

Dr Ken Catchpole

Director of Surgical Safety and Human Factors Research

Cedars Sinai Medical Center

Los Angeles

Ken.catchpole@cshs.org

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

ken.catchpole@cshs.org

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