Patient Safety

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Patient Safety Clinical Handover

• Kiaran Flanagan, Consultant Acute Physician
• Acute Medicine Team

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Acute Medicine
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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

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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
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What is patient safety?
The avoidance, prevention and amelioration of
adverse outcomes or injuries stemming from the
process of healthcare
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Or ...
Actions undertaken by individuals and
organizations to protect health care recipients
from being harmed by the effects of health care
services
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Our Aim

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

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The scale of the problem
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Factors Affecting Patient Safety

• Patient
• Task
• Individual
• Team
• Working Conditions
• Organisational
• Governmental Regulatory

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A couple of little stories...
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Fell over on the way to the shed
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Fell over on the way to the bathroom
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Fell over on the way to the kitchen
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Its all about cheese...
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Never Events
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Human Factors
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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
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Why Clinical Handover?
Continuity of sufficient and relevant
information(and appropriate action) to suitably
experienced clinicians is vital to the safety of
our patients
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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
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What its 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

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Getting practical

• Morning Clinical Handover 0830 CDU
• Evening Clinical Handover 1700 ED Seminar Room
• H_at_N Clinical Handover 2030 Control Room

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Even with the best planning in the world...