10/23/2015. Don t drop the baton: Improving handover communication from the CMPA s perspective

Transcription

1 Don t drop the baton: Improving handover communication from the CMPA s perspective This is an abridged version of presentation with cases and videos removed Dr Janet Nuth, Physician Risk Manager CMPA Associate Professor Dept of Emergency Medicine, University of Ottawa CSIM, PEI, Oct 16, 2015 Faculty: Employee of: Faculty / Presenter Disclosure Dr Janet Nuth CMPA Relationshipswith commercial interests: - Grants / Research Support: None - Speakers Bureau / Honoraria: None - Consulting Fees: None - Other: None Conflict of Interest - I have no financial or professional affiliation with any organization that can be perceived as a conflict of interest in the context of this presentation. Objectives 1. Describe medical legal risks associated with poorly performed handovers 2. Name 3 barriers to performing effective handovers 3. Identify 5 strategies for improving handovers Copyright - Not to be distributed without written permission of CMPA. No audio recording, video recording, or photography is allowed without CMPA's permission. Information is for general educational purposes only and is not intended to provide specific professional medical or legal advice or constitute a standard of care. 1

2 case Handovers Top 5 Messages Remember handovers are of high medico-legal risk Interruptions, distractions should be limited Standardize content. Start with the sickest person Know the pending tasks and contingency plan Synthetize and document the essential data Remember hand-over is of high medical legal risk CMPA www. For hospitals, the hand-off has long been the Bermuda Triangle of health care: dangerous errors and oversights can occur in the gap when a patient is moved to another unit or turned over to a new nurse or doctor during a shift change. Laura Landro, The Wall Street Journal, 6/28/06 2

3 Serious Medical Errors 80% Poor handoffs implicated in 20% of US malpractice claims involving diagnostic errors Ann Int Med 2006;145; 448 Joint Commission Perspective Aug 2012 US Malpractice Legal Outcome Comparison Legal Actions Closed % of malpractice claims in US involving trainees: Handoff problems were identified as the contributing factor Arch Intern Med. 2007; 167(19): Favourable 27% 73% Communication MD : MD Unfavourable 62% 38% CMPA all legal actions 3

4 Study Review of 459 incidents related to handover Calls for universal standards and training of errors due to absence of handover omissions of critical info. re patient s condition omissions of critical info. re care plan Journal for Healthcare Quality 2012;00(0): p1-7 MDs Overestimate Effectiveness What are the barriers? Time 88% MDs rated their handovers as good 15.4% receivers found important info lacking: management, investigations, disposition Emerg Med Aust 2007 Oct 19 (5) Interruptions Communication style Missing Information Lack of standardization 4

5 How Can Handovers Be Improved? Face-face Whenever Possible VS Limit Distractions 98% of all handoffs were interrupted BMJ Qual Saf 2013; 22:203 5

6 Effect of interruptions RNs have 12% increase in med errors if interrupted MDs will fail to return to 18.5 % of interrupted tasks Do not disturb and No page policies Distractions No crewmember can engage in any activity which could distract any flight crewmember during critical phase of flight J Am Med Inform Ass 2000, 7; ; Ann EM Med Ped Emerg Care 2011;27: 826; Start With the Sickest Person Standardize the Content 6

7 Know Pending Tasks & Contingency Plan Examples of Handover Mnemonics SBAR/ ISBAR ANTICipate DRAW IPASS Am J of Medical Quality Vol24:3, May/june 2009; SBAR Handover Mnemonics Crit Care Med 2012 Vol. 40, No. 7 ituation ackground ssessment & Action Much less loss of info in all clinical categories < adverse events (CPR, post-op complications) post implementation ecommendation / read-back 7

8 ANTICipate Handover Mnemonics I-PASS Handover Mnemonic dministrative data ew Information (clinical update) asks (what needs to be done) llness (is the patient sick?) ontingency plan/ code status Illness severity Patient summary Action list Situation awareness and contingency plan Synthesis by receiver Use one of the Handover mnemonics with your partner 10,740 pt admissions at 9 sites Pre/post intervention: Medical error rates 23% (24.5 vs 18.8/100 admissions, p<0.001) Preventable medical error rates 30% (4.7 vs 3.3 events/ 100 admissions, p< 0.001) Duration of handoff unchanged (2.4 vs. 2.5 min/ pt) SBAR Situation, Background, Assessment, Recommendation / read-back IPASS Illness, Patient Summary, Action list, Situational awareness / contingency plan, Synthesis by receiver 8

9 Telephone Transfer What communication tool might have prevented this? The Read-back 1 study: Promote Active Listening During Handover Read-back only occurred 17% of time Document your essential points Ok so the Blood CS, urine CS and US are still pending. If still febrile tomorrow I ll get ID to see. BMJ Qual Saf 2013; 22:203 CMPA www. 9

10 Documentation 86% of clinically important issues from overnight period were not documented 2205 Transfer Dr. Smith: Sx for brain ca, D/C last week, Seizure tonight, IV phenytoin loaded, GCS =15, discussed NeuroSx Pending tasks Lytes, CT head (1700 booked) Plan If bl work, CT unchanged D/C in am if no repeat Seizure NeuroSx will see fri, Start Phenytoin 300mg po od If recurrent Seizure or CT call Neuro Sx to admit Documentation Payne CE, Stein JM, Leong T, et al. BMJ Qual Saf (2012) 42 yr old RSCP X 20min 1400 K+ Fhx Card, Phx -, EKG N, Ck, TnI N R/O ACS Pending C x-r, 8 hrs Ck, TnI, EKG If N-ASA outpt Card clinic If abn- Card to see, NSTEMI protocol 10

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12 10/23/2015 Handovers Documentation Top 5 Messages Remember handovers are of high medico-legal risk Interruptions, distractions should be limited Standardize content. Start with the sickest person Know the pending tasks and contingency plan Ms. Donna Mackenzie, General Council, Gowlings Synthetize and document the essential data Resources Good Practices Guide 2012 What will you do differently tomorrow? 12

13 10/23/2015 Cmpa Website References Riesenberg, LA, et al. Residents and Attending Handoffs: A systematic review. Acad Med 2009;84(12): Arora, V. et al Hospitalist Handoffs: A systematic review and task force recommendations J Hosp Med 2009;4: Bump,G. et al. Resident Sign-out and patient handoffs: opportunities for improvement. Teach and Learn Med 2011; 23(2); Raduma-Tomas, M, et al. Doctors handovers in hospitals: a literature review BMJ Qual Saf 2011; 20: Dunn,W, Murphy, J. The patient handoff: Medicine s formula one moment..chest 2008;134;9-12 Stromer, A. et al. Changes in medical errors after implementation of a handoff program. NEJM 2014; 371: Riesenberg et al. Systematic Review of Handoff Mnemonics Literature American Journal of Medical Quality.2009; 24: Improving Handoff Communication. Joint Commission Resources Published by the Joint Commission on Accreditation of Healthcare Organizations. CMPA Risk Management Education 13