Ir J Med Sci DOI 10.1007/s11845-015-1278-5
ORIGINAL ARTICLE
Implementation of a surgical handover tool in a busy tertiary referral centre: a complete audit cycle J. P. Gibbons • E. Nugent • S. Tierney D. Kavanagh
•
Received: 25 January 2015 / Accepted: 21 February 2015 Ó Royal Academy of Medicine in Ireland 2015
Abstract Background The implementation of the European worktime directive has created increased transitions of care during weekends as doctors adhere to a shift-work structure. This raises concerns over continuity of care and patient safety. To address this, doctors must develop a time efficient yet safe system of handover of patients to the team on-call. Intuitively weekend care provides the ideal setting to develop a handover tool. Aim To develop and implement a process of surgical handover and to improve weekend discharge rate on a surgical service. Methods Data was collected at three time-points over a 6 months period (October 2013–March 2014) encompassing development, implementation, re-evaluation and modification of the handover process. The outcomes measured were: number of inpatients, number of weekend discharges, length of stay (LOS) of inpatients recorded for the four weekends within the month, and total emergency response team (ERT) calls each month. Results Mean number of included patients each month was 294 (r = 14). Following the introduction of weekend handover there was a 40 % increase in weekend discharges which was consistent for subsequent time-points (p \ 0.05). Following the second intervention there was a statistically significant reduction in mean LOS from 13 to 5.4 days (p \ 0.05) and the total number of ERT calls for the month reduced from 12 to 4 (p \ 0.05). Conclusions The standardisation of weekend handover using a combination of an electronic tool supplemented J. P. Gibbons (&) E. Nugent S. Tierney D. Kavanagh Department of Surgery, Tallaght Hospital, Tallaght, Dublin 24, Ireland e-mail: [email protected]
with verbal handover is feasible. It resulted in a significant improvement in surrogate markers of patient care quality. Keywords
Surgical signout Handover tool
Introduction With the implementation of European Working Time Directive (EWTD) there is a change in the model of care delivered by doctors to their patients [1, 2]. There are increased transitions of care during the week as doctors adhere to a mandatory shift-work structure. The traditional model of patient care has been abolished such that patients may see a range of doctors of varying experience and familiarity with the patients’ clinical case within a 24 h period. This issue becomes most evident at weekends when the primary team must handover responsibility of their patients to the team on-call. This has lead to much work into the reform of the long accepted formula for medical care and much research into the topic of handover [1–7]. It has prompted national reports into patient safety, with Sir John Lilleyman, Medical director of the National Patient Safety Agency stating that ‘‘Handover of care is one of the most perilous procedures in medicine’’ [8]. As EWTD becomes established the frequency of handovers will increase. There is an onus upon doctors to strive to make it as efficient as possible whilst minimising both errors and disruption of continuity of care [9]. The use of system-based standardized checklists has been shown to reduce communication errors in the handover [10]. The British Medical Association have stated that all units should implement their own specific handover with details on who should perform it where and when it
123
Ir J Med Sci
should be performed and what should be included in the checklist [8, 11]. It is difficult to have a national checklist for handover applicable to all hospitals as there is too much inter-hospital variance in terms of patient management issues. In fact, within a single institution there is huge interdisciplinary variation in the priorities of care. LeBlanc et al. [11] suggest seven headings that should be considered in developing a surgical handover checklist: patient co morbidities, working diagnosis, readiness for theatre, recent physiological stability, associated injuries, mechanism of injury, outstanding issues. The advantage to incorporating a structured checklist has been shown with nursing handover as it reduces irrelevant and speculative information, and it reduces time spent by avoiding repetition [12]. Studies have consistently shown that doctors feel handover represents an essential component of patient care. Many advocate a formal teaching module during undergraduate medical education or at the start of life as a doctor in training [11]. The institute of medicine has made the recommendation that all trainees have formal training in handover [13]. The use of a handover tool introduces a new communication challenge for doctors as complex management plans for multiple patients must be succinctly communicated to the recipient in a time efficient manner. Poor communication in handover will lead to duplication of tests, missing data, medication errors, delayed diagnosis, delayed treatments, increased length of stay and most importantly poor outcomes for the patient [11]. Donaldson et al. [14] recently published mortality figures for a 3-year period from an intensive care unit setting (2010–2012). It was demonstrated that 5 % of these mortalities were attributable to poor handover [14]. The addition of a written handover increases retention of information up to 99 % [2, 11]. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) 2003 revealed that up to 70 % of sentinel events are attributed to breakdown in communication and are distributed throughout malpractice claims [15, 16]. It has been shown that medical errors are one of the leading causes of death in the US [17]. A robust handover tool reduces the potential for introducing error. Effective communication is the hallmark of healthcare organizations that are successful in providing safe high quality care for their patients [15]. The subject of this study was night and weekend handover as it is known that the greatest uncertainty regarding patient care occurs during these time periods when less staff are available [18]. The aim of this study was to evaluate how to improve care of surgical patients in regards to (1) reducing length of stay through prompt discharge over the weekend, and (2) reduction in patient deterioration events measured by emergency response team (ERT) calls by early detection and anticipation of these events.
123
Materials and methods This audit was carried out within the department of surgery amongst the specialities of general surgery (upper GI and colorectal) and vascular surgery in a University Teaching Hospital. Using the electronic patient data, the surgical inpatients who occupied a bed overnight during the weekend were recorded for each weekend in the specified month. Data was collected from four weekends in October and December 2013 and March 2014. Each weekend was recorded as a separate event; therefore, any patient whose stay spanned greater than one weekend would be counted more than once. The length of stay, readmission rate (re-admitted under an emergency surgical speciality within 14 days of discharge), number of emergency response team (ERT) calls, and date of discharge were all recorded. Analysis of the results between audit cycles was carried out using Microsoft Excel (2007) using the Student’s t test. The first data collection was carried out in October 2013 prior to any intervention. The first intervention to facilitate surgical handover involved implementation of an electronic surgical sign-out as described previously [1]. This was combined with a face-to-face verbal handover of patients on a Friday evening to the registrar on-call for the weekend. This was first employed in November 2013 with dedicated educational sessions at grand rounds to teach all participants and regular emails and feedback meetings amongst registrars and consultants to continually improve the quality of information being included within the signout template. The second data collection was carried out in December 2013. After analysis of the data and further feedback from the participants a second intervention was implemented in January 2014. This involved the addition of electronic handover of all surgical inpatients by each team to the oncall team using an agreed upon format for information provided including patient details, diagnosis, current issues, tests awaiting, patient specific weekend plan. This was rolled out in late January 2014 and was again reinforced with educational sessions at weekly surgical meetings and regular feedback meetings between registrars and consultants. The third data collection was carried out in March 2014.
Results The results are shown in Table 1. The mean number of included patients each month was 294 (r = 14). Following the introduction of weekend handover there was a 40 % increase in weekend discharges which was consistent for subsequent time-points (p \ 0.05, Student t-test), see Fig. 1.
Ir J Med Sci Table 1 Audit results
Month
Inpatients
Weekend discharges
% discharges (%)
Readmissions
LOS of those d/c Mean
Median
S.E.
ERT calls Total
October
284
30
10.6
0
13
5
16.4
7
December
288
42
14.6
0
16.2
6.5
34.7
12
March
310
46
14.8
0
5.4
4
5.1
4
Fig. 1 Weekend discharges for each month. *Indicates statistically significant difference (p \ 0.05, Student t-test)
Following the second intervention there was a statistically significant reduction in mean LOS from 13 to 5.4 days (p \ 0.05, Student t-test) between October 2013 and March 2014, see Fig. 2. Finally the total number of ERT calls for the month reduced from 12 to 4 for December 2013 and March 2014, respectively, (p \ 0.05, Student’s t-test), see Fig. 3. None of the patients discharged at weekends required readmission for the same clinical condition within 30 days.
Discussion There is a growing number of research articles and quality improvement reports looking into the question of patient safety and the use of handover tools [4–6, 9, 11, 18–20]. Jardine et al. [6] showed that implementation of a standardized intranet handover tool resulted in a significant improvement in the quality of handovers amongst foundation grade doctors. Various reports show that doctor satisfaction increases with implementation of handover tools [4, 9, 19, 20]. In the United Kingdom they have been successful in maintaining the preEWTD doctor to patient ratios [21]. However, there is no
information available for Irish hospitals regarding the ratio of patients to doctors which is now very pertinent with implementation of the EWTD. If there is a reduction, it further labours the need for more training and further research into the area of handover tool development. The aim of the current study was to implement and assess the impact of a handover process on surrogate markers of weekend patient care. The introduction and refinement of a standardized surgical handover tool resulted in a significant and sustained increase in the number of patients discharged during the weekends studied. Timely discharge is the cornerstone of efficient hospital management and may reduce the exposure of patients to hospital-acquired infections. The handover tool allowed communication and retention of the clinical plans for individual patients which improved patient management as evidenced by the decrease in mean LOS. By creating a tool that requires the primary team to formulise a plan for each patient, the potential issues for a patient are identified for the attention of the on-call team. This may lead to a reduced potential for emergencies to arise over the weekend and encourages the primary team to communicate with the entire healthcare team the plan for the patient for the subsequent 72 h. The reduced potential
123
Ir J Med Sci Fig. 2 Mean length of stay for inpatients that remained in hospital over weekends. *Indicates statistically significant difference (p \ 0.05, Student t-test)
Fig. 3 Total emergency response team calls for each month studied. *Indicates statistically significant difference (p \ 0.05, Student t-test)
for emergencies follows into the normal working week as the continuum of care is ameliorated, and this was seen in the study with a significantly reduced number of ERT calls. This study is limited by the heterogeneity of the patient population. A combination of acute and elective patients provides a number of confounding factors which may impact upon the validity of the surrogate markers of care used. However, this patient population is representative of the case mix in all University Teaching Hospitals in Ireland. In conclusion, this study provides evidence of improvement using objective markers of patient care with the implementation and refinement of a handover tool. It is essential for any surgical unit to, not only develop a robust handover tool, but, to continually audit and improve it as a dynamic tool to help deliver the best care to our patients.
123
Conflict of interests
None.
References 1. Ryan S, O’Riordan J, Tierney S, Conlon K, Ridgway P (2011) Impact of a new electronic handover system in surgery. Int J Surg 9:217–220 2. Bhabra G, Mackeith S, Monteiro P, Pothier DD (2007) An experimental comparison of handover methods. Ann R Coll Surg Engl 89:298 3. Raptis DA, Fernandes C, Chua W, Boulos PB (2009) Electronic software significantly improves quality of handover in a London teaching hospital. Health Inform J 15:191–198 4. Din N, Ghaderi S, O’Connell R, Johnson T (2012) Strengthening surgical handover: developing and evaluating the effectiveness of a handover tool to improve patient safety. BMJ Qual Improv Rep 1(u492):w164
Ir J Med Sci 5. Bradley A (2014) Improving the quality of patient handover on a surgical ward. BMJ Qual Improv Rep 3(u201797):w1958 6. Jardine AGM, Page T, Bethune R, Mourant P, Deol P, Bowden C et al (2014) Bring on the weekend-Improving the quality of junior doctor weekend handover. BMJ Qual Improv Rep 2(u202379): w1297 7. (2007) Safe handover: guidance from the working time directive working party. http://www.rcseng.ac.uk/publications/docs: RCSE 8. Association BM (2004) Safe handover, safe patients: guidance on clinical handover for clinicians and managers: British Medical Association 9. McCann L, McHardy K, Child S (2007) Passing the buck: clinical handovers at a New Zealand tertiary hospital. NZ Med J 120:1–10 10. Catchpole KR, De Leval MR, Mcewan A, Pigott N, Elliott MJ, Mcquillan A et al (2007) Patient handover from surgery to intensive care: using formula 1 pit-stop and aviation models to improve safety and quality. Pediatric Anesth 17:470–478 11. LeBlanc J, Donnon T, Hutchison C, Duffy P (2014) Development of an orthopedic surgery trauma patient handover checklist. Can J Surg 57:9 12. Sexton A, Chan C, Elliott M, Stuart J, Jayasuriya R, Crookes P (2004) Nursing handovers: do we really need them? J Nurs Manag 12:37–42
13. (2001) Crossing the quality chasm: a new health system for the 21st century: Institute of Medicine. Committee on Quality of Health Care in America. National Academies Press 14. Donaldson LJ, Panesar SS, Darzi A (2014) Patient-Safety-Related Hospital Deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. PLoS Med 11:e1001667 15. Alvarado K, Lee R, Christoffersen E, Fram N, Boblin S, Poole N et al (2006) Transfer of accountability: transforming shift handover to enhance patient safety. Healthc Q 9:75–79 16. Organizations JCoAoH (2003) Sentinel event statistics: december 17, 2003. Oakbrook Terrace IL, JCAHO 17. Kohn LT, Corrigan JM, Donaldson MS (2000) To err is human::building a Safer Health System. National Academies Press 18. Johner AM, Merchant S, Aslani N, Planting A, Ball CG, Widder S et al (2013) Acute general surgery in Canada: a survey of current handover practices. Can J Surg 56:E24 19. Al-Benna S, Al-Ajam Y, Alzoubaidi D (2009) Burns surgery handover study: trainees’ assessment of current practice in the British Isles. Burns 35:509–512 20. Culwick C, Devine C, Coombs C (2014) Improving surgical weekend handover. BMJ Qual Improv Rep 3(u203298):w1533 21. Andrew F, Hodgson H, Newbery N (2010) Impact of EWTD on patient: doctor ratios and working practices for junior doctors in England and Wales 2009. Clin Med 10:330–335
123
ORIGINAL ARTICLE
Implementation of a surgical handover tool in a busy tertiary referral centre: a complete audit cycle J. P. Gibbons • E. Nugent • S. Tierney D. Kavanagh
•
Received: 25 January 2015 / Accepted: 21 February 2015 Ó Royal Academy of Medicine in Ireland 2015
Abstract Background The implementation of the European worktime directive has created increased transitions of care during weekends as doctors adhere to a shift-work structure. This raises concerns over continuity of care and patient safety. To address this, doctors must develop a time efficient yet safe system of handover of patients to the team on-call. Intuitively weekend care provides the ideal setting to develop a handover tool. Aim To develop and implement a process of surgical handover and to improve weekend discharge rate on a surgical service. Methods Data was collected at three time-points over a 6 months period (October 2013–March 2014) encompassing development, implementation, re-evaluation and modification of the handover process. The outcomes measured were: number of inpatients, number of weekend discharges, length of stay (LOS) of inpatients recorded for the four weekends within the month, and total emergency response team (ERT) calls each month. Results Mean number of included patients each month was 294 (r = 14). Following the introduction of weekend handover there was a 40 % increase in weekend discharges which was consistent for subsequent time-points (p \ 0.05). Following the second intervention there was a statistically significant reduction in mean LOS from 13 to 5.4 days (p \ 0.05) and the total number of ERT calls for the month reduced from 12 to 4 (p \ 0.05). Conclusions The standardisation of weekend handover using a combination of an electronic tool supplemented J. P. Gibbons (&) E. Nugent S. Tierney D. Kavanagh Department of Surgery, Tallaght Hospital, Tallaght, Dublin 24, Ireland e-mail: [email protected]
with verbal handover is feasible. It resulted in a significant improvement in surrogate markers of patient care quality. Keywords
Surgical signout Handover tool
Introduction With the implementation of European Working Time Directive (EWTD) there is a change in the model of care delivered by doctors to their patients [1, 2]. There are increased transitions of care during the week as doctors adhere to a mandatory shift-work structure. The traditional model of patient care has been abolished such that patients may see a range of doctors of varying experience and familiarity with the patients’ clinical case within a 24 h period. This issue becomes most evident at weekends when the primary team must handover responsibility of their patients to the team on-call. This has lead to much work into the reform of the long accepted formula for medical care and much research into the topic of handover [1–7]. It has prompted national reports into patient safety, with Sir John Lilleyman, Medical director of the National Patient Safety Agency stating that ‘‘Handover of care is one of the most perilous procedures in medicine’’ [8]. As EWTD becomes established the frequency of handovers will increase. There is an onus upon doctors to strive to make it as efficient as possible whilst minimising both errors and disruption of continuity of care [9]. The use of system-based standardized checklists has been shown to reduce communication errors in the handover [10]. The British Medical Association have stated that all units should implement their own specific handover with details on who should perform it where and when it
123
Ir J Med Sci
should be performed and what should be included in the checklist [8, 11]. It is difficult to have a national checklist for handover applicable to all hospitals as there is too much inter-hospital variance in terms of patient management issues. In fact, within a single institution there is huge interdisciplinary variation in the priorities of care. LeBlanc et al. [11] suggest seven headings that should be considered in developing a surgical handover checklist: patient co morbidities, working diagnosis, readiness for theatre, recent physiological stability, associated injuries, mechanism of injury, outstanding issues. The advantage to incorporating a structured checklist has been shown with nursing handover as it reduces irrelevant and speculative information, and it reduces time spent by avoiding repetition [12]. Studies have consistently shown that doctors feel handover represents an essential component of patient care. Many advocate a formal teaching module during undergraduate medical education or at the start of life as a doctor in training [11]. The institute of medicine has made the recommendation that all trainees have formal training in handover [13]. The use of a handover tool introduces a new communication challenge for doctors as complex management plans for multiple patients must be succinctly communicated to the recipient in a time efficient manner. Poor communication in handover will lead to duplication of tests, missing data, medication errors, delayed diagnosis, delayed treatments, increased length of stay and most importantly poor outcomes for the patient [11]. Donaldson et al. [14] recently published mortality figures for a 3-year period from an intensive care unit setting (2010–2012). It was demonstrated that 5 % of these mortalities were attributable to poor handover [14]. The addition of a written handover increases retention of information up to 99 % [2, 11]. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) 2003 revealed that up to 70 % of sentinel events are attributed to breakdown in communication and are distributed throughout malpractice claims [15, 16]. It has been shown that medical errors are one of the leading causes of death in the US [17]. A robust handover tool reduces the potential for introducing error. Effective communication is the hallmark of healthcare organizations that are successful in providing safe high quality care for their patients [15]. The subject of this study was night and weekend handover as it is known that the greatest uncertainty regarding patient care occurs during these time periods when less staff are available [18]. The aim of this study was to evaluate how to improve care of surgical patients in regards to (1) reducing length of stay through prompt discharge over the weekend, and (2) reduction in patient deterioration events measured by emergency response team (ERT) calls by early detection and anticipation of these events.
123
Materials and methods This audit was carried out within the department of surgery amongst the specialities of general surgery (upper GI and colorectal) and vascular surgery in a University Teaching Hospital. Using the electronic patient data, the surgical inpatients who occupied a bed overnight during the weekend were recorded for each weekend in the specified month. Data was collected from four weekends in October and December 2013 and March 2014. Each weekend was recorded as a separate event; therefore, any patient whose stay spanned greater than one weekend would be counted more than once. The length of stay, readmission rate (re-admitted under an emergency surgical speciality within 14 days of discharge), number of emergency response team (ERT) calls, and date of discharge were all recorded. Analysis of the results between audit cycles was carried out using Microsoft Excel (2007) using the Student’s t test. The first data collection was carried out in October 2013 prior to any intervention. The first intervention to facilitate surgical handover involved implementation of an electronic surgical sign-out as described previously [1]. This was combined with a face-to-face verbal handover of patients on a Friday evening to the registrar on-call for the weekend. This was first employed in November 2013 with dedicated educational sessions at grand rounds to teach all participants and regular emails and feedback meetings amongst registrars and consultants to continually improve the quality of information being included within the signout template. The second data collection was carried out in December 2013. After analysis of the data and further feedback from the participants a second intervention was implemented in January 2014. This involved the addition of electronic handover of all surgical inpatients by each team to the oncall team using an agreed upon format for information provided including patient details, diagnosis, current issues, tests awaiting, patient specific weekend plan. This was rolled out in late January 2014 and was again reinforced with educational sessions at weekly surgical meetings and regular feedback meetings between registrars and consultants. The third data collection was carried out in March 2014.
Results The results are shown in Table 1. The mean number of included patients each month was 294 (r = 14). Following the introduction of weekend handover there was a 40 % increase in weekend discharges which was consistent for subsequent time-points (p \ 0.05, Student t-test), see Fig. 1.
Ir J Med Sci Table 1 Audit results
Month
Inpatients
Weekend discharges
% discharges (%)
Readmissions
LOS of those d/c Mean
Median
S.E.
ERT calls Total
October
284
30
10.6
0
13
5
16.4
7
December
288
42
14.6
0
16.2
6.5
34.7
12
March
310
46
14.8
0
5.4
4
5.1
4
Fig. 1 Weekend discharges for each month. *Indicates statistically significant difference (p \ 0.05, Student t-test)
Following the second intervention there was a statistically significant reduction in mean LOS from 13 to 5.4 days (p \ 0.05, Student t-test) between October 2013 and March 2014, see Fig. 2. Finally the total number of ERT calls for the month reduced from 12 to 4 for December 2013 and March 2014, respectively, (p \ 0.05, Student’s t-test), see Fig. 3. None of the patients discharged at weekends required readmission for the same clinical condition within 30 days.
Discussion There is a growing number of research articles and quality improvement reports looking into the question of patient safety and the use of handover tools [4–6, 9, 11, 18–20]. Jardine et al. [6] showed that implementation of a standardized intranet handover tool resulted in a significant improvement in the quality of handovers amongst foundation grade doctors. Various reports show that doctor satisfaction increases with implementation of handover tools [4, 9, 19, 20]. In the United Kingdom they have been successful in maintaining the preEWTD doctor to patient ratios [21]. However, there is no
information available for Irish hospitals regarding the ratio of patients to doctors which is now very pertinent with implementation of the EWTD. If there is a reduction, it further labours the need for more training and further research into the area of handover tool development. The aim of the current study was to implement and assess the impact of a handover process on surrogate markers of weekend patient care. The introduction and refinement of a standardized surgical handover tool resulted in a significant and sustained increase in the number of patients discharged during the weekends studied. Timely discharge is the cornerstone of efficient hospital management and may reduce the exposure of patients to hospital-acquired infections. The handover tool allowed communication and retention of the clinical plans for individual patients which improved patient management as evidenced by the decrease in mean LOS. By creating a tool that requires the primary team to formulise a plan for each patient, the potential issues for a patient are identified for the attention of the on-call team. This may lead to a reduced potential for emergencies to arise over the weekend and encourages the primary team to communicate with the entire healthcare team the plan for the patient for the subsequent 72 h. The reduced potential
123
Ir J Med Sci Fig. 2 Mean length of stay for inpatients that remained in hospital over weekends. *Indicates statistically significant difference (p \ 0.05, Student t-test)
Fig. 3 Total emergency response team calls for each month studied. *Indicates statistically significant difference (p \ 0.05, Student t-test)
for emergencies follows into the normal working week as the continuum of care is ameliorated, and this was seen in the study with a significantly reduced number of ERT calls. This study is limited by the heterogeneity of the patient population. A combination of acute and elective patients provides a number of confounding factors which may impact upon the validity of the surrogate markers of care used. However, this patient population is representative of the case mix in all University Teaching Hospitals in Ireland. In conclusion, this study provides evidence of improvement using objective markers of patient care with the implementation and refinement of a handover tool. It is essential for any surgical unit to, not only develop a robust handover tool, but, to continually audit and improve it as a dynamic tool to help deliver the best care to our patients.
123
Conflict of interests
None.
References 1. Ryan S, O’Riordan J, Tierney S, Conlon K, Ridgway P (2011) Impact of a new electronic handover system in surgery. Int J Surg 9:217–220 2. Bhabra G, Mackeith S, Monteiro P, Pothier DD (2007) An experimental comparison of handover methods. Ann R Coll Surg Engl 89:298 3. Raptis DA, Fernandes C, Chua W, Boulos PB (2009) Electronic software significantly improves quality of handover in a London teaching hospital. Health Inform J 15:191–198 4. Din N, Ghaderi S, O’Connell R, Johnson T (2012) Strengthening surgical handover: developing and evaluating the effectiveness of a handover tool to improve patient safety. BMJ Qual Improv Rep 1(u492):w164
Ir J Med Sci 5. Bradley A (2014) Improving the quality of patient handover on a surgical ward. BMJ Qual Improv Rep 3(u201797):w1958 6. Jardine AGM, Page T, Bethune R, Mourant P, Deol P, Bowden C et al (2014) Bring on the weekend-Improving the quality of junior doctor weekend handover. BMJ Qual Improv Rep 2(u202379): w1297 7. (2007) Safe handover: guidance from the working time directive working party. http://www.rcseng.ac.uk/publications/docs: RCSE 8. Association BM (2004) Safe handover, safe patients: guidance on clinical handover for clinicians and managers: British Medical Association 9. McCann L, McHardy K, Child S (2007) Passing the buck: clinical handovers at a New Zealand tertiary hospital. NZ Med J 120:1–10 10. Catchpole KR, De Leval MR, Mcewan A, Pigott N, Elliott MJ, Mcquillan A et al (2007) Patient handover from surgery to intensive care: using formula 1 pit-stop and aviation models to improve safety and quality. Pediatric Anesth 17:470–478 11. LeBlanc J, Donnon T, Hutchison C, Duffy P (2014) Development of an orthopedic surgery trauma patient handover checklist. Can J Surg 57:9 12. Sexton A, Chan C, Elliott M, Stuart J, Jayasuriya R, Crookes P (2004) Nursing handovers: do we really need them? J Nurs Manag 12:37–42
13. (2001) Crossing the quality chasm: a new health system for the 21st century: Institute of Medicine. Committee on Quality of Health Care in America. National Academies Press 14. Donaldson LJ, Panesar SS, Darzi A (2014) Patient-Safety-Related Hospital Deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. PLoS Med 11:e1001667 15. Alvarado K, Lee R, Christoffersen E, Fram N, Boblin S, Poole N et al (2006) Transfer of accountability: transforming shift handover to enhance patient safety. Healthc Q 9:75–79 16. Organizations JCoAoH (2003) Sentinel event statistics: december 17, 2003. Oakbrook Terrace IL, JCAHO 17. Kohn LT, Corrigan JM, Donaldson MS (2000) To err is human::building a Safer Health System. National Academies Press 18. Johner AM, Merchant S, Aslani N, Planting A, Ball CG, Widder S et al (2013) Acute general surgery in Canada: a survey of current handover practices. Can J Surg 56:E24 19. Al-Benna S, Al-Ajam Y, Alzoubaidi D (2009) Burns surgery handover study: trainees’ assessment of current practice in the British Isles. Burns 35:509–512 20. Culwick C, Devine C, Coombs C (2014) Improving surgical weekend handover. BMJ Qual Improv Rep 3(u203298):w1533 21. Andrew F, Hodgson H, Newbery N (2010) Impact of EWTD on patient: doctor ratios and working practices for junior doctors in England and Wales 2009. Clin Med 10:330–335
123
