Patient Safety & Clinical Handover

1. Patient Safety & Clinical Handover Kiaran Flanagan, Consultant Acute Physician Acute Medicine Team

3. Acute Medicine

4. Acute Medicine • Busy • Lots of sick people • Lots of doctors • Wide spectrum of practice • You have to keep you eye on the ball... • HIGH RISK AREA OF CLINICAL PRACTICE

5. What is our minimum standard? “The very first requirement in a hospital is it that it should do the sick no harm” Notes on Hospitals, 1863

6. What is patient safety? “The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare”

7. Or ... Actions undertaken by individuals and organizations to protect health care recipients from being harmed by the effects of health care services

9. Our Aim • No needless deaths • No needless pain or suffering • No unwanted waits • No helplessness • No waste • For anyone....

10. The scale of the problem

12. Factors Affecting Patient Safety • Patient • Task • Individual • Team • Working Conditions • Organisational • Governmental & Regulatory

13. A couple of little stories...

14. Fell over on the way to the shed

15. Fell over on the way to the bathroom

16. Fell over on the way to the kitchen

17. Its all about cheese...

18. Never Events

19. Human Factors

20. What is Clinical Handover? The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis National Patient Safety Agency, 2005

21. Why Clinical Handover? Continuity of sufficient and relevant information(and appropriate action) to suitably experienced clinicians is vital to the safety of our patients

22. Responsibility & Accountability “Individuals and organisations have a shared responsibility to ensure that safe continuity of information and responsibility takes place” “Information provided during handovers influences the delivery of care for the whole shift”

23. What it’s supposed to achieve • Sufficient and relevant information should be exchanged • Clinically unstable patients made known to senior and covering clinicians • Unstable patients receive review • Juniors adequately briefed of concerns from personnel and previous shifts • At risk areas/ situations identified

24. Getting practical • Morning Clinical Handover 08:30 CDU • Evening Clinical Handover 17:00 ED Seminar Room • H@N Clinical Handover 20:30 Control Room

25. Even with the best planning in the world...