Revving up patient safety in Aust hospitals

An ABC online article has compared Australian hospitals with racing cars.

Professor Paul Barach, director of the Injury Risk Management Research Centre at the University of New South Wales has said that hospitals have a lot to learn from the extraordinary pit stop coordination of the Ferrari Formula 1 racing team.

By managing patient “hand-overs” within the complex hospital system with similar precision, Australia’s health system has the best chance of protecting patients from the real risk of harm from human error. 

The recent Special Commission of Inquiry into the NSW Hospital System, lead by Peter Garling SC, highlighted patient handovers as one of the most common emerging risks to patient safety in NSW hospitals.

There is no reason to believe the situation is any different in other states.
 
Thousands of “hand-overs” occur in hospitals every day, and devastating mistakes can occur.

The World Health Organisation (WHO) listed “Communication during patient care hand-overs” as one of its High 5 patient safety initiatives.

Improving effective communication throughout the hospital is a lead patient safety goal put forth in the United States by the Joint Commission. The Australian Commission on Quality and Safety in Health Care (ACQSHC) has identified clinical hand-overs as a particular focus for 2009.

Nearly 70% of all preventable hospital mishaps occur because of communication problems.
 
Researchers from the University of Oxford examining teamwork and patient hand-overs following surgery travelled to Maranello, Italy to examine how the Ferrari Formula 1 racing team performs during pit stops.

They implemented lessons learned about teamwork to reduce technical errors during patient hand-overs. In one setting, errors were reduced by an impressive 42%, demonstrating that processes and protocols developed in other industries could be adapted to particular areas of medical practice.

The strategies of Resource Crew Management in the airline industry may also be applicable to environments such as operating rooms and intensive care units. These are valuable lessons for Australia.
 
Handover communications in Australian hospitals occur within complex, adaptive systems, meaning organisational culture is the key to change.

Improving outcomes requires an understanding of the link between processes and results. Focusing on the system, instead of the individual, will direct attention to the processes and outcomes of care.
 
As NSW’s Garling Report recommended, we need tools to make information readily accessible and transparent.

We need to implement a performance reporting system that can identify “hotspots” for further study whilst working to reduce the variability inherent in the normal processes.

There needs to be a sustained effort to provide feedback about individual performance and set performance expectations in a blame free culture.