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Use of strategies from high-reliability organisations to the patient hand-off by resident Physicians: practical implications
Abstract and Figures
Limits on resident hours increase the frequency of patient hand-offs and may contribute to information transfer problems that contribute to adverse outcomes. This study analysed attributes that affect hand-off accuracy, including use of data summaries and end-of-shift transfer strategies from high-reliability organisations.
Mixed-method study combining qualitative interviews and surveys of residents in internal medicine, surgery, paediatrics and ob-gynaecology.
Strategies in resident hand-offs mirrored the intent of end-off-shift transfers in high-reliability organisations, but approaches differed, reflecting the fluid nature of residents' work and focusing on multiple patients with differing needs. Clinical skills were relevant to hand-off quality for both participants. Cross-coverage, more common duty hour limits, had a negative effect on hand-off accuracy. It significantly increased the likelihood of unplanned changes in care and errors attributed to the hand-off. For surgery residents, asynchronous hand-offs without true interactions increased. Data summaries contributed to efficiency, but were associated with greater incidence of surprises and errors, even when they did not replace verbal hand-offs. Third parties, particularly nursing, functioned as redundant systems that prevented or trapped many hand-off errors.
Hand-offs depended on residents' clinical skills, suggesting a need for education and supervision of junior residents' transfers. Research is needed to explore how to conduct effective hand-offs under shortened duty periods. This should assess how transfer strategies and data summaries could enhance efficiency and effectiveness, and how they could substitute when a verbal interactive hand-off is not feasible.
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... Research shows that when patient information is communicated orally (i.e., human-human handoff), it is particularly prone to decay in terms of completeness and accuracy [44,52]. Communication failures due to inability to synthesize information, insufficient time or difficulties dealing with patient emergencies [53] have a direct impact on errors of omission and information imprecision [9,39,44]. On the other hand, when patient information is exchanged asynchronously (via the use of ICTs), ICTs often fail to reflect the realities and intricacies of clinical work, thus resulting in information dissemination that is either irrelevant or far too vague for various clinical contexts [4,50]. ...
... Consistent with previous research on patient information handoffs (e.g., [9,39,44,52,53]), our findings suggest that human-human handoffs are detrimental to information accuracy and completeness, particularly when the exchange includes hard data such as physiological measurements or treatment parameters. However, our network analysis shows that human-human handoffs are more likely to occur in connection to unfolding care activities, and less as stand-alone information exchanges during change of shift encounters. ...
Objective
The design of health ICTs, as well as human factors, have been shown to influence patient information quality. The aim of this study was to understand how patterns of interaction between these factors influence information quality aspects in a critical care environment.
Method
We conducted an ethnographic study of socio-technical information handoffs in a critical care unit. Data collection methods included non-participant observations and semi-structured interviews. Methodological principles from network analysis (SNA, VNA) were used to develop visual network diagrams, as well as to analyze the composition of the information network and its influence on patient information quality.
Results
The network patterns that emerged uncover that human actors have many information processing and dissemination roles at the critical care unit. However, ICTs play key network roles, acting as information intermediaries and gatekeepers. We further identify three types of information handoffs in the critical care environment – human-human, human-ICT and ICT-human. On the one hand, we find that human-human and ICT-human handoffs influence contextual and intrinsic aspects of patient information, such as information completeness and accuracy. On the other hand, human-ICT handoffs influence information accessibility and representational quality, such as consistency and interpretability.
Discussion
The results suggest that standardizing change of shift handoff communication may not be sufficient to prevent information decay in complex care trajectories. In particular, we argue that ensuring information consistency and interpretability across disciplines and professions is as important as ensuring information completeness and accuracy during change of shift handoffs. ICT and workflow design opportunities are discussed as means to address overlapping or conflicting information needs across disciplines and professions, increase information consistency, and reduce information redundancy across the network.
... [15][16][17] Protocols and checklists are employed to ensure that key information is transmitted during handoffs throughout healthcare. [18][19][20] Some electronic health records (EHRs) have integrated standardized handoffs, 21 including nurse-to-nurse handoffs 15,22 and perioperative nursing handoffs specifically. 23,24 Nevertheless, handoff-related information gaps are common for postoperative patients. ...
Objective
Situational awareness and anticipatory guidance for nurses receiving a patient after surgery are keys to patient safety. Little work has defined the role of artificial intelligence (AI) to support these functions during nursing handoff communication or patient assessment. We used interviews to better understand how AI could work in this context.
Materials and Methods
Eleven nurses participated in semistructured interviews. Mixed inductive-deductive thematic analysis was used to extract major themes and subthemes around roles for AI supporting postoperative nursing.
Results
Five themes were generated from the interviews: (1) nurse understanding of patient condition guides care decisions, (2) handoffs are important to nurse situational awareness, but multiple barriers reduce their effectiveness, (3) AI may address barriers to handoff effectiveness, (4) AI may augment nurse care decision making and team communication outside of handoff, and (5) user experience in the electronic health record and information overload are likely barriers to using AI. Important subthemes included that AI-identified problems would be discussed at handoff and team communications, that AI-estimated elevated risks would trigger patient re-evaluation, and that AI-identified important data may be a valuable addition to nursing assessment.
Discussion and Conclusion
Most research on postoperative handoff communication relies on structured checklists. Our results suggest that properly designed AI tools might facilitate postoperative handoff communication for nurses by identifying specific elevated risks faced by a patient, triggering discussion on those topics. Limitations include a single center, many participants lacking of applied experience with AI, and limited participation rate.
... Prior to the study, we conducted a literature review to determine what information is generally deemed crucial in perioperative handovers. 1,2,4,11,[14][15][16][17] A draft checklist of 40 items was then developed through a Delphi process with seven participants and three final rounds to reach consensus ( Figure 1 and Electronic Supplementary Material [ESM], eAppendix). One of the researchers (Z. ...
Purpose:
Intraoperative handovers are common in anesthesia practice and are associated with increased patient morbidity and mortality. Checklists may improve transfer of information during handovers. This before-and-after study sought to examine the effect of a checklist on intraoperative handover. We hypothesized that introducing a handover checklist would improve our primary outcome of completeness of data transfer.
Methods:
From February to August 2016, anesthesia providers (residents, fellows, and consultants) at a single tertiary academic center participated in a handover study. Baseline handovers between anesthesia care providers were videotaped, analyzed, and compared with anesthetic records. An intraoperative handover checklist was then introduced, and handovers completed with it were videotaped. The completeness of handovers was compared between the baseline routine and checklist groups. The primary outcome was completeness of information transfer.
Results:
Sixty-seven anesthesia providers participated in the study. Use of the intraoperative handover checklist improved completeness of handover by 6% (95% confidence interval [CI], 2 to 10; P < 0.01). There was no relationship observed between the provider (consultants/fellows vs resident) of the handovers and the degree of completeness (95% CI, 3 to 8; P = 0.33). Complexity had a significant impact on the handover completeness with low or high complexity cases more completely handed over than those of medium complexity both before and after the intervention-a 6% increase for low complexity (95% CI, 1 to 11; P = 0.02) and a 9% increase for high complexity (95% CI, 3 to 14; P < 0.01).
Conclusion:
Use of a checklist during intraoperative handovers improved completeness of data transfer. Handover checklists should be considered to improve handover completeness.
... [12][13][14] Protocolized or checklist based handoffs are employed to ensure that key information is transmitted throughout healthcare. [15][16][17] Similar methods of standardization have been applied to nurse-to-nurse handoffs [12,18] and perioperative nursing handoffs specifically. [19,20] Nevertheless, handoff-related information gaps are common for postoperative patients. ...
Objective: Situational awareness and anticipatory guidance for nurses receiving a patient after surgery are key to patient safety. Little work has defined the role of artificial intelligence (AI) to support these functions during nursing handoff communication or patient assessment. We used interviews and direct observations to better understand how AI could work in this context.
Materials and Methods: 58 handoffs were observed of patients entering and leaving the post-anesthesia care unit at a single center. 11 nurses participated in semi-structured interviews. Mixed inductive-deductive thematic analysis extracted major themes and subthemes around roles for AI supporting postoperative nursing.
Results: Four themes emerged from the interviews: (1) Nurse understanding of patient condition guides care decisions, (2) Handoffs are important to nurse situational awareness; problem focus and information transfer may be improved by AI, (3) AI may augment nurse care decision making and team communication, (4) User experience and information overload are likely barriers to using AI. Key subthemes included that AI-identified problems would be discussed at handoff and team communications, that AI-estimated elevated risks would trigger patient re-evaluation, and that AI-identified important data may be a valuable addition to nursing assessment.
Discussion and Conclusion: Most research on postoperative handoff communication relies on structured checklists. Our results suggest that properly designed AI tools might facilitate postoperative handoff communication for nurses by identifying elevated risks faced by a specific patient, triggering discussion on those topics.
... Accredited training programs must prepare and validate a healthcare trainee's behavioral competencies in conducting safe patient handovers. These teamwork behaviors are essential non-technical skills required to achieve highly reliable interprofessional communication in a variety of ambulatory and inpatient settings [12,13]. ...
Background
As part of the worldwide call to enhance the safety of patient handovers of care, the Association of American Medical Colleges (AAMC) requires that all graduating students “give or receive a patient handover to transition care responsibly” as one of its Core Entrustable Professional Activities (EPAs) for Entering Residency. Students therefore require educational activities that build the necessary teamwork skills to perform structured handovers. To date, a reliable instrument designed to assess teamwork competencies, like structured communication, throughout their preclinical and clinical years does not exist.
Method
Our team developed an assessment instrument that evaluates both the use of structured communication and two additional teamwork competencies necessary to perform safe patient handovers. This instrument was utilized to assess 192 handovers that were recorded from a sample of 229 preclinical medical students and 25 health professions students who participated in a virtual course on safe patient handovers. Five raters were trained on utilization of the assessment instrument, and consensus was established. Each handover was reviewed independently by two separate raters.
Results
The raters achieved 72.22 % agreement across items in the reviewed handovers. Krippendorff’s alpha coefficient to assess inter-rater reliability was 0.6245, indicating substantial agreement among the raters. A confirmatory factor analysis (CFA) demonstrated the orthogonal characteristics of items in this instrument with rotated item loadings onto three distinct factors providing preliminary evidence of construct validity.
Conclusions
We present an assessment instrument with substantial reliability and preliminary evidence of construct validity designed to evaluate both use of structured handover format as well as two team competencies necessary for safe patient handovers. Our assessment instrument can be used by educators to evaluate learners’ handoff performance as early as their preclinical years and is broadly applicable in the clinical context in which it is utilized. In the journey to optimize safe patient care through improved teamwork during handovers, our instrument achieves a critical step in the process of developing a validated assessment instrument to evaluate learners as they seek to accomplish this goal.
This article reports a study aimed at developing and validating an Operating Room–to-ICU Patient Handover checklist. Deficient or absent clinical handovers, or failures to transfer information, responsibility, and accountability can have unwanted consequences for hospitalized patients. Clinical handovers are practiced every day, in many ways, in all institutional health care settings. Despite increasing demand for structured processes to guide clinical handovers, standardized handover bundles for nurses and physicians are limited in the intensive care unit. As a result of this study an Operating Room–to-ICU Patient Handover checklist was created, which was based on a quantitative and qualitative research design. This checklist is expected to be helpful for proper patient transfers between these critical areas, ensuring patient safety and efficient quality management.
This text presents a four-step approach for applying communicative concepts to driving automation, including: scoping, piloting, designing, and testing. It further provides experimental data on how practical human-human communication strategies can be applied to interaction in automated vehicles.
The book explores the role of communication and the nature of situation awareness in automated vehicles to ensure safe and usable automated vehicle operation. It covers the issue of interaction in automated vehicles by providing insight into communicative concepts, the transfer of control in human-teams, and how these concepts can be applied in automated vehicles. The theoretical framework is built on by presenting experimental findings, design workshop output and providing a demonstration of prototype generation for automated assistants that addresses a wide range of performance outcomes within human-machine interaction.
Aimed at professionals, graduate students, and academic researchers in the fields of ergonomics, automotive engineering, transportation engineering, and human factors, this text:
Discusses experimental findings on how practical human-human communication strategies can be applied to interaction in automated vehicles.
Provides a four-step approach for applying communicative concepts to driving automation, including: scoping, piloting, designing and testing.
Explores the role of distributed situation awareness in automated vehicles.
Covers communication and system awareness in response to multiple complex road scenarios.
Provides design guidelines for automation-human handover design.
Non-verbal communication, such as eye contact between drivers and pedestrians, has been regarded as one way to reduce accident risk. So far, studies have assumed rather than objectively measured the occurrence of eye contact. We address this research gap by developing an eye contact detection method and testing it in an indoor experiment with scripted driver-pedestrian interactions at a pedestrian crossing. Thirty participants acted as a pedestrian either standing on an imaginary curb or crossing an imaginary one-lane road in front of a stationary vehicle with an experimenter in the driver’s seat. In half of the trials, pedestrians were instructed to make eye contact with the driver; in the other half, they were prohibited from doing so. Both parties’ gaze was recorded using eye trackers. An in-vehicle stereo camera recorded the car’s point of view, a head-mounted camera recorded the pedestrian’s point of view, and the location of the driver’s and pedestrian’s eyes was estimated using image recognition. We demonstrate that eye contact can be detected by measuring the angles between the vector joining the estimated location of the driver’s and pedestrian’s eyes, and the pedestrian’s and driver’s instantaneous gaze directions, respectively, and identifying whether these angles fall below a threshold of 4°. We achieved 100% correct classification of the trials involving eye contact and those without eye contact, based on measured eye contact duration. The proposed eye contact detection method may be useful for future research into eye contact.
Background
Miscommunication is a leading cause of preventable incidents in healthcare. A number of checklists have been created in an attempt to improve patient outcomes with only a small impact. However, the 2009 WHO Surgical Safety Checklist demonstrated benefits in terms of reduced morbidity and mortality. Our aim was to determine whether use of a Postanaesthesia Team Handover (PATH) checklist would reduce hypoxaemic events in the postanaesthesia care unit (PACU).
Methods
This single-centre, prospective, pre-/post-implementation study was conducted between February 2019 and July 2020 in the PACU of Versailles Private Hospital, Paris, France. Pre-PATH implementation data were collected for 294 consecutive adult patients (≥18 yr old) admitted to the PACU and post-PATH implementation data were collected for 293 consecutive patients. The primary outcome was the rate of hypoxaemic events post-surgery during PACU stay.
Results
The rates of hypoxaemic events were 4.1% (11/267 [95% confidence interval {CI}: 2.3–7.2%]) before the PATH checklist was introduced and 0.8% (2/266 [95% CI: 0.2–2.7%]) after. Patients in the PATH group were 5.6 times (odds ratio [OR] [95% CI: 1.3–33.6], P=0.041) less likely to have a hypoxaemic event than those in the control group. The handover process in the PATH checklist group also had significantly less interruptions (38.6% control vs 20.7% PATH; OR=2.5 [95% CI: 1.7–3.7]; P<0.0001).
Conclusions
Implementation of the PATH checklist in adult patients post-surgery was associated with a reduction in the rate of hypoxaemic events in the PACU. These findings support standardisation of the handover process with checklists following anaesthesia and surgery.
Clinical trial registration
NCT03972423.
The HEALTH Passport: Helping everyone achieve longterm health. A medical student programme for prevention of long term conditions and promoting behavioural change
Generalizing the concepts of joint activity developed by Clark (1996), we describe key aspects of team coordination. Joint activity depends on interpredictability of the participants' attitudes and actions. Such interpredictability is based on common ground-pertinent knowledge, beliefs, and assumptions that are shared among the involved parties. Joint activity assumes a basic compact, which is an agreement (often tacit) to facilitate coordination and prevent its breakdown. One aspect of the Basic Compact is the commitment to some degree of aligning multiple goals. A second aspect is that all parties are expected to bear their portion of the responsibility to establish and sustain common ground and to repair it as needed. We apply our understanding of these features of joint activity to account for issues in the design of automation. Research in software and robotic agents seeks to understand and satisfy requirements for the basic aspects of joint activity. Given the widespread demand for increasing the effectiveness of team play for complex systems that work closely and collaboratively with people, observed shortfalls in these current research efforts are ripe for further exploration and study.
In health care organizations, the division of labor and a need for continuous, 24-hour treatment subjects patients to multiple transitions in care. These transitions, or “handovers,” are potential points of failure that have seen very little study. We observed transitions of care in five hospital emergency departments as part of a larger study on safety in emergency care and found that in addition to many other differences in work patterns among the various hospitals, very different sorts of handovers occurred in different contexts, and these differences appeared to reflect a common structure. Using these observations, we have proposed a conceptual framework for characterizing handover events. The ability to characterize certain types of transitions may help to clarify future studies, while assisting in the development of interventions to better fit the context of clinical work.
Context Limitationsindutyhoursforphysicians-in-trainingintheUnitedStateswereestablished by the Accreditation Council for Graduate Medical Education (ACGME)and implemented on July 1, 2003. The association of these changes with mortalityamong hospitalized patients has not been well established.Objective To determine whether the change in duty hour regulations was associ-atedwithrelativechangesinmortalityinhospitalsofdifferentteachingintensitywithinthe US Veterans Affairs (VA) system.Design, Setting, and Patients An observational study of all unique patients(N=318636)admittedtoacute-careVAhospitals(N=131)usinginterruptedtimese-ries analysis with data from July 1, 2000, to June 30, 2005. All patients had principaldiagnoses of acute myocardial infarction (AMI), congestive heart failure, gastrointes-tinal bleeding, or stroke or a diagnosis related group classification of general, ortho-pedic,orvascularsurgery.Logisticregressionwasusedtoexaminethechangeinmor-tality for patients in more vs less teaching-intensive hospitals before (academic years2000-2003) and after (academic years 2003-2005) duty hour reform, adjusting forpatient comorbidities, common time trends, and hospital site.Main Outcome Measure All-location mortality within 30 days of hospital admis-sion.Results In postreform year 1, no significant relative changes in mortality were ob-served for either medical or surgical patients. In postreform year 2, the odds of mor-tality decreased significantly in more teaching-intensive hospitals for medical patientsonly. Comparing a hospital having a resident-to-bed ratio of 1 with a hospital havingaresident-to-bedratioof0,theoddsofmortalitywerereducedforpatientswithAMI(odds ratio [OR], 0.48; 95% confidence interval [CI], 0.33-0.71), for the 4 medicalconditions together (OR, 0.74; 95% CI, 0.61-0.89), and for the 3 medical conditionsexcluding AMI (OR, 0.79; 95% CI, 0.63-0.98). Compared with hospitals in the 25thpercentileofteachingintensity,therewasanabsoluteimprovementinmortalityfromprereform year 1 to postreform year 2 of 0.70 percentage points (11.1% relative de-crease) and 0.88 percentage points (13.9% relative decrease) in hospitals in the 75thand 90th percentile of teaching intensity, respectively, for the combined medicalconditions.Conclusions The ACGME duty hour reform was associated with significant relativeimprovementinmortalityforpatientswith4commonmedicalconditionsinmoreteach-ing-intensive VA hospitals in postreform year 2. No associations were identified forsurgical patients.
This is an empirical and theoretical examination of high reliability organizations. The empirical referents are the U.S. Navy's nuclear aircraft carriers and the air traffic control system of the U.S. Federal Aviation Administration. Three modes of organizational behavior are observed ranging from routine or bureaucratic to high-tempo to emergency. Each mode has distinctive authority patterns, communications pathways and leadership perspectives.Since 1984, an interdisciplinary group of scholars at Berkeley has been involved in making observations of and theorizing about “high reliability organizations” (HROs), which operate technical systems that are very beneficial, costly, and hazardous. Major operational errors in these organizations are likely to produce catastrophic consequences; therefore, HROs take on the dual goals of sustaining delivery at maximum capacity and operating in nearly error-free fashion. They are so effective that the probability of serious error is very low.Other kinds of organizations systematically use trial-and-error learning. HROs, however, have less confidence in this process for conducting hazardous operations, because their next error may be their last trial.This paper draws on experience with two of the Navy's nuclear aircraft carriers and the Federal Aviation Administration's air-traffic control system. Current theories derive primarily from studies of “failure-tolerant,” trial-and-error operating bureaucracies. Is this literature a sure guide to HROs? Do the phenomena challenge contemporary thinking about complex organizations? “High-reliability” operations reveal a range of theoretical (and operational) surprises. The remainder of this discussion explores a single dimension of this theoretical arena.
Most writing on sociological method has been concerned with how accurate facts can be obtained and how theory can thereby be more rigorously tested. In The Discovery of Grounded Theory, Barney Glaser and Anselm Strauss address the equally Important enterprise of how the discovery of theory from data--systematically obtained and analyzed in social research--can be furthered. The discovery of theory from data--grounded theory--is a major task confronting sociology, for such a theory fits empirical situations, and is understandable to sociologists and laymen alike. Most important, it provides relevant predictions, explanations, interpretations, and applications. In Part I of the book, "Generation Theory by Comparative Analysis," the authors present a strategy whereby sociologists can facilitate the discovery of grounded theory, both substantive and formal. This strategy involves the systematic choice and study of several comparison groups. In Part II, The Flexible Use of Data," the generation of theory from qualitative, especially documentary, and quantitative data Is considered. In Part III, "Implications of Grounded Theory," Glaser and Strauss examine the credibility of grounded theory. The Discovery of Grounded Theory is directed toward improving social scientists' capacity for generating theory that will be relevant to their research. While aimed primarily at sociologists, it will be useful to anyone Interested In studying social phenomena--political, educational, economic, industrial-- especially If their studies are based on qualitative data.
Many medical injuries are preventable, but there are few reported successful strategies to prevent such injuries. Previous work identified coverage by house staff not primarily responsible for the patient (cross-coverage) as a significant correlate of risk for preventable adverse events. A four-month intervention--computerized sign-outs--was introduced in 1993 in an urban teaching hospital to improve continuity of care during cross-coverage and thereby reduce risk for preventable adverse events.
A previously tested confidential self-report system was used to identify adverse events, which were defined as unexpected complications of medical therapy that resulted in increased length of stay or disability at discharge. A panel of three board-certified internists confirmed events and evaluated preventability based on case summaries.
After the intervention, the rate of preventable adverse events among the 3,747 patients admitted to the medical service decreased from 1.7% to 1.2% (p < 0.10). Both univariate and multivariate analysis revealed no association between cross coverage and preventable adverse events after the intervention. In the baseline period, the odds ratio (OR) for a patient suffering a preventable adverse event during cross coverage was 5.2 (95% confidence interval [CI], 1.5-18.2; p = 0.01), but was no longer significant after the intervention (OR, 1.5; 95% CI, 0.2-9.0).
House staff are willing participants in efforts to measure and improve the quality of health care systems. The intervention may have reduced the risk for medical injury associated with discontinuity of inpatients care. Four years after the end of the study, the computerized sign-out program remained an integral part of the computing support system for house staff and was widely used.