Strengthening surgical handover: Developing and evaluating the effectiveness of a handover tool to improve patient safety.

Din, Nizar; Ghaderi, Shahrzad; O’Connell, Rachel; Johnson, Tayo

doi:10.1136/bmjquality.u492.w164

Cited by 19 publications

(18 citation statements)

References 4 publications

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“…Din et al [ 4 ] did corroborate findings from other studies that formalising handover through introduction of a handover tool improved quality of handover [ 5 , 6 , 7 ]. Ashton [ 5 ] incorporated SBAR (Situation, Background, Assessment and Recommendations) in their handover tool.…”

Section: Introductionsupporting

confidence: 57%

“…Most involve the introduction of a handover tool to succinctly summarise information. Din et al [ 4 ] created a tool which used a traffic light system to help staff appropriately prioritise patients requiring weekend review. This was shown to improve quality of, and confidence in, weekend handover of surgical patients, as well as improve efficiency of weekend ward rounds.…”

Section: Introductionmentioning

confidence: 99%

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Improving the quality of patient handover on a surgical ward

Bradley

2014

BMJ Qual Improv Report

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The European Working Time Directive means safe patient hand over is imperative. It is the responsibility of every doctor and an issue of patient safety and clinical governance [1]. The aims of this project were to improve the quality of patient handover between combined assessment unit (CAU) and surgical ward FY1 doctors.The Royal College of Surgeons England (RCSEng) guidelines on surgical patient handover [1] were used as the standard. Data was collected throughout November 2013. A handover tool was then introduced and attached to the front of patient notes when a patient was transferred from CAU to the surgical ward. The doctor handing over the patient and the ward doctor receiving the handover signed this document. Policy was also changed so that handover should take place once the patient had received senior review on the CAU and was deemed appropriate for transfer to the surgical ward. Data from the handover tool was collated and checked against the list of surgical admission for February 2014.The number of patients handed over improved from 15 % to 45%. The quality of patient handover also improved. 0 patient handovers in November 2013 included all of the information recommended by the RCSEng guidelines. 100% of the patient handovers in February 2014 contained all the recommended information.Introduction of a handover tool and formalisation of timing of patient handover helped to improve quality and number of patients being handed over. Further work needs to be done to improve safe handover of surgical patients, particularly out of hours.

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Section: Introductionsupporting

confidence: 57%

Section: Introductionmentioning

confidence: 99%

Improving the quality of patient handover on a surgical ward

Bradley

2014

BMJ Qual Improv Report

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“…Clinical handover is an essential aspect of the provision of safe health care. However, one impediment to identifying problems in communication is the difficulty in measuring outcomes from effective communication and handover . Communication proformas to measure outcomes require significant detail; however, this can become laborious and time‐consuming for medical staff.…”

Section: Discussionmentioning

confidence: 99%

Potentially avoidable issues in urology mortality cases in Australia: identification and improvements

Gupta

Stewart

Cottell

et al. 2020

ANZ Journal of Surgery

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Background: This study aimed to identify the most common potentially avoidable factors in urology deaths, focusing on the lessons that can be learnt. Methods: This study analysed data from a well-established and comprehensive peer review audit of surgical deaths in Australian hospitals (excluding New South Wales) from 2009 to 2015, focusing on urology cases with identified areas for improvement in patient management. Of all audited deaths, 11% (79/719) had serious clinical management issues with a total of 109 individual clinical management issues identified. These were categorized based on perioperative stage (preoperative, intraoperative or post-operative), followed by thematic analysis within each stage. Results: The study found preoperative issues to be the most common (n = 48), followed by post-operative issues (n = 32) with intraoperative issues less common (n = 13). Communication issues were seen at all three stages (n = 16). Overall, the most common theme was at the preoperative stage; inadequate preoperative assessment (n = 27). More specifically, the most common preoperative assessment issues involved a failure to order necessary preoperative investigations, or to administer necessary preoperative treatment (e.g. prophylactic antibiotics). The most common communication issue was between teams and at handover, often involving failure by junior medical staff to communicate issues to the responsible surgical consultant. Conclusion: Urological surgical cases with potentially avoidable mortality constitute a small, but important subset of deaths. The analysis of these cases can inform various stakeholders to improve the quality and safety of urological surgical care.© 2020 Royal Australasian College of Surgeons ANZ J Surg 90 (2020) 719-724ANZJSurg.com

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“…The problem identified is not unique to this district general hospital, but has been recognised by medical and surgical juniors at both secondary and tertiary centres [7][8][9][10] …”

Section: Introductionmentioning

confidence: 99%

Improving weekend patient handover

Ashton

2013

BMJ Qual Improv Report

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The Royal College of Physicians state that ‘handover, particularly of temporary ‘on-call’ responsibility, has been identified as a point at which errors are likely to occur’ [1].Working a weekend on-call covering medical wards is often busy and stressful for all junior doctors, with added pressure in trying to identify patients and tasks amongst several different pieces of paper and making important care escalation.All handover sheets from a random weekend were collected and studied. Only 57% of patients listed had the minimum expected 3 patient identifiers [2] included and just 11% had any indication of escalation planning. They were also often written on scrap pieces of paper and included varying levels of relevant patient background and information.After liaison with junior doctors and the handover committee, involving senior medical clinicians, a new handover sheet was created and uploaded onto the trust intranet, to rectify some of the problems identified. Junior doctors were also educated about the changes to weekend handover.At 2 months post-introduction, another set of weekend handover sheets were collected. All medical wards used the handover sheets for documentation of patients and tasks at a weekend and inclusion of 3 patient identifiers rose to 80%. There was also a big increase noted in clinical information and background included at weekend handover and anecdotally made weekend handover easier and less stressful. There was also increased consideration of escalation planning.The handover sheet is now being rolled out trust-wide in medicine and introduced to surgical colleagues.

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Strengthening surgical handover: Developing and evaluating the effectiveness of a handover tool to improve patient safety.

Cited by 19 publications

References 4 publications

Improving the quality of patient handover on a surgical ward

Improving the quality of patient handover on a surgical ward

Potentially avoidable issues in urology mortality cases in Australia: identification and improvements

Improving weekend patient handover

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