GoKawiilIntroduction
It has been nearly a decade since seminal reports and associated research documenting the surprising frequency of accidental injury in healthcare were published in the UK and around the world (Vincent, Neale and Woloshynowych 2001). Around that time, complex and systemic causes of a sequence of probable accidental deaths at the Bristol Royal Infirmary were emerging, while research at Great Ormond Street Hospital was finding that small, seemingly innocuous events could accumulate to affect mortality and morbidity (de Leval et al. 2000). In these incidents, the technical challenges of complex surgery in very high risk patients meant that teams were sometimes unable to prevent errors that subsequently affected patients.
All complex systems are faced with the same problem: although humans are fallible and make mistakes, they cannot be designed out. This is not just because humans design, maintain, operate and promulgate technology, tools and tasks that allow regular systems function, but also because they keep all these disparate components together. Complex systems themselves are naturally unsafe. It is the people and teams within them that allow them to achieve high standards (Dekker 2002).
It is with this in mind that there has been much speculation on how to learn from other industries to address safety issues. We at Great Ormond Street Hospital were able to learn from the Ferrari F1 team, which comprises a complex system, and apply this knowledge to improving a critical handover process, thus developing new ways to think about safety in high risk surgical care.
High Risk Handovers
Providing continuity of care between frequently changing teams is an area of vulnerability in any complex system. With the increasing transfer of patients between clinical areas, and the reduction in working hours following the European Working Time Directive, continuity of care has vastly increased in importance in the clinical field. The transfer from the operating theatre to the intensive care unit is one of the most difficult stages in the care of a child, concluded Kennedy (2001). These children, often only days old and having had a hugely invasive surgical operation, can be extremely unstable and will require support from a wide number of inotropes, vasoactive agents, other drugs and several invasive monitoring lines. They need to be moved from safe ventilation and monitoring to portable equipment while they are transported a short distance into the ICU (in Great Ormond Street Hospital this was only 30 or 40 meters). Here they are returned to safe monitoring and ventilation. Bed space is configured around these patients, with infusion pumps placed on a stand and plugged into the power socket, and monitoring lines plugged into the monitors, which are then appropriately zeroed. During the same period, the surgeon and anaesthetist hand over to the receiving doctors and nurses in the ICU the vital information required for the care of the patient, which they have gathered during pre-operative assessments and several hours of surgery. At this point, the ICU staff may have little knowledge of the patient.
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