Patient handovers within the hospital: translating knowledge from motor racing to healthcare

被引:49
作者
Catchpole, Ken [1 ]
Sellers, Richard [2 ]
Goldman, Allan [3 ]
McCulloch, Peter [1 ]
Hignett, Sue [2 ]
机构
[1] Univ Oxford, Nuffield Dept Surg, Oxford OX3 9DU, England
[2] Univ Loughborough, Dept Human Sci, Loughborough, Leics, England
[3] Great Ormond St Hosp Sick Children, London, England
来源
QUALITY & SAFETY IN HEALTH CARE | 2010年 / 19卷 / 04期
关键词
SAFETY; TECHNOLOGY; SURGERY; FAILURE;
D O I
10.1136/qshc.2009.026542
中图分类号
R19 [保健组织与事业(卫生事业管理)];
学科分类号
摘要
Introduction This paper expands the analogy between motor racing team pit stops and patient handovers. Previous studies demonstrated how the handover of patients following surgery could be improved by learning from a motor racing team. This has been extended to include contributions from several motor racing teams, and by examining transfers at several different interfaces at a non-specialist UK teaching hospital. Methods Letters of invitation were sent to the technical managers of nine Formula 1 motor racing teams. Semistructured interviews were carried out at a UK teaching hospital with 10 clinical staff involved in the handover of patients from surgery to recovery and intensive care. Results Three themes emerged from the motor racing responses; (1) proactive learning with briefings and checklists to prevent errors; (2) active management using technology to transfer information, and (3) post hoc learning from the storage and analysis of electronic data records. The eight healthcare themes were: historical working practice; problems during transfer; poor awareness of handover protocols; poor team coordination; time pressure; lack of consistency in handover practice; poor communication of important information; and awareness that handover was a potential threat to patient safety. Conclusions The lessons from motor racing can be applied to healthcare for proactive planning, active management and post hoc learning. Other high-risk industries see standardisation of working practices, interpersonal communication, consistency and continuous development as fundamental for success. The application of these concepts would result in improvements in the quality and safety of the patient handover process.
引用
收藏
页码:318 / 322
页数:5
相关论文
共 34 条
  • [1] [Anonymous], 1990, Qualitative Evaluation and Research Methods, DOI DOI 10.1002/NUR.4770140111
  • [2] Technical performance: Relation between surgical dexterity and technical knowledge
    Bann, S
    Khan, MS
    Datta, VK
    Darzi, AW
    [J]. WORLD JOURNAL OF SURGERY, 2004, 28 (02) : 142 - 147
  • [3] Castledine George, 2006, Br J Nurs, V15, P524
  • [4] Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality
    Catchpole, Ken R.
    De Leval, Marc R.
    McEwan, Angus
    Pigott, Nick
    Elliott, Martin J.
    McQuillan, Annette
    Macdonald, Carol
    Goldman, Allan J.
    [J]. PEDIATRIC ANESTHESIA, 2007, 17 (05) : 470 - 478
  • [5] A prospective study of patient safety in the operating room
    Christian, CK
    Gustafson, ML
    Roth, EM
    Sheridan, TB
    Gandhi, TK
    Dwyer, K
    Zinner, MJ
    Dierks, MM
    [J]. SURGERY, 2006, 139 (02) : 159 - 173
  • [6] Adapting to new technology in the operating room
    Cook, RI
    [J]. HUMAN FACTORS, 1996, 38 (04) : 593 - 613
  • [7] Human factors and cardiac surgery: A multicenter study
    de Leval, MR
    Carthey, J
    Wright, DJ
    Farewell, VT
    Reason, JT
    [J]. JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY, 2000, 119 (04) : 661 - 670
  • [8] Ellis Jane, 2004, Nurs Times, V100, P36
  • [9] Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room
    Espin, S.
    Lingard, L.
    Baker, G. R.
    Regehr, G.
    [J]. QUALITY & SAFETY IN HEALTH CARE, 2006, 15 (03): : 165 - 170
  • [10] Patterns of communication breakdowns resulting in injury to surgical patients
    Greenberg, Caprice C.
    Regenbogen, Scott E.
    Studdert, David M.
    Lipsitz, Stuart R.
    Rogers, Selwyn O.
    Zinner, Michael J.
    Gawande, Atul A.
    [J]. JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS, 2007, 204 (04) : 533 - 540