The role of dynamic trade-offs in creating safety - a qualitative study of handover across care boundaries in emergency care

The paper aims to demonstrate how the study of everyday clinical work can contribute novel insights into a common and stubborn patient safety problem – the vulnerabilities of handover across care boundaries in emergency care. Based on a dialectical interpretation of the empirical evidence gathered in five National Health Service organisations, the paper argues that performance variability is an essential component in the delivery of safe care, as practitioners translate tensions they encounter in their everyday work into safe practices through dynamic trade-offs based on their experience and the requirements of the specific situation. The findings may shed new light on the vulnerabilities of the handover process, and they might help explain why improvements to handover have remained largely elusive and what type of future recommendations may be appropriate for improving patient safety

Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO) : primary research

Background and objectives: Handover and communication failures are a recognised threat to patient safety. Handover in emergency care is a particularly vulnerable activity owing to the high-risk context and overcrowded conditions. In addition, handover frequently takes place across the boundaries of organisations that have different goals and motivations, and that exhibit different local cultures and behaviours. This study aimed to explore the risks associated with handover failure in the emergency care pathway, and to identify organisational factors that impact on the quality of handover. Methods: Three NHS emergency care pathways were studied. The study used a qualitative design. Risks were explored in nine focus group-based risk analysis sessions using failure mode and effects analysis (FMEA). A total of 270 handovers between ambulance and the emergency department (ED), and the ED and acute medicine were audio-recorded, transcribed and analysed using conversation analysis. Organisational factors were explored through thematic analysis of semistructured interviews with a purposive convenience sample of 39 staff across the three pathways. Results: Handover can serve different functions, such as management of capacity and demand, transfer of responsibility and delegation of aspects of care, communication of different types of information, and the prioritisation of patients or highlighting of specific aspects of their care. Many of the identified handover failure modes are linked causally to capacity and patient flow issues. Across the sites, resuscitation handovers lasted between 38 seconds and 4 minutes, handovers for patients with major injuries lasted between 30 seconds and 6 minutes, and referrals to acute medicine lasted between 1 minute and approximately 7 minutes. Only between 1.5% and 5% of handover communication content related to the communication of social issues. Interview participants described a range of tensions inherent in handover that require dynamic trade-offs. These are related to documentation, the verbal communication, the transfer of responsibility and the different goals and motivations that a handover may serve. Participants also described the management of flow of patients and of information across organisational boundaries as one of the most important factors influencing the quality of handover. This includes management of patient flows in and out of departments, the influence of time-related performance targets, and the collaboration between organisations and departments. The two themes are related. The management of patient flow influences the way trade-offs around inner tensions are made, and, on the other hand, one of the goals of handover is ensuring adequate management of patient flows. Conclusions: The research findings suggest that handover should be understood as a sociotechnical activity embedded in clinical and organisational practice. Capacity, patient flow and national targets, and the quality of handover are intricately related, and should be addressed together. Improvement efforts should focus on providing practitioners with flexibility to make trade-offs in order to resolve tensions inherent in handover. Collaborative holistic system analysis and greater cultural awareness and collaboration across organisations should be pursued

Safety of patient handover in emergency care – results of a qualitative study

The paper presents the results of a qualitative study investigating safety of patient handover in the emergency care pathway. Semi-structured interviews were conducted with 39 practitioners from two NHS ambulance services and three hospitals in England. Thematic analysis identified two main themes: (1) there are tensions in the activity of handover, which practitioners deal with by making dynamic trade-offs based on their expertise and depending on the particular situation; (2) the management of patient and information flows across organisational boundaries is a key factor affecting the quality and safety of handover. The results suggest that there is a need for greater collaboration across organisational boundaries, and that organisational policies and procedures should provide flexibility to practitioners enabling them to make necessary local trade-offs based on their expertis

Learning from incidents in health care : critique from a Safety-II perspective

Patients are continually being put at risk of harm, and health care organisations are struggling to learn effectively from past experiences in order to improve the safe delivery and management of care. Learning from incidents in health care is based on the traditional safety-engineering paradigm, where safety is defined by the absence of negative events (Safety-I). In this paper we make suggestions for the policy and practice of learning from incidents in health care by offering a critique based on a Safety-II perspective. In Safety-II thinking safety is defined as an ability - to make dynamic trade-offs and to adjust performance in order to meet changing demands and to deal with disturbances and surprises. The paper argues that health care organisations might improve their ability to learn from past experience by studying not only what goes wrong (i.e. incidents), but also by considering what goes right, i.e. by learning from everyday clinical work

What keeps patients safe? A Resilience Engineering perspective

In this paper I explore the potential contribution a Resilience Engineering perspective could offer towards a better understanding and improvement of patient safety. I argue that performance variability is an essential component in the delivery of safe care, as practitioners translate tensions they encounter in their everyday work into safe practices through dynamic trade-offs based on their experience and the requirements of the specific situation. Health care organisations and health policy makers should consider identifying ways that enable organisations to learn about performance variability and trade-offs from everyday clinical work

The role of organizational factors in how efficiency-thoroughness trade-offs potentially affect clinical quality dimensions – a review of the literature

Purpose The purpose of this paper is to increase knowledge of the role organizational factors have in how health personnel make efficiency-thoroughness trade-offs, and how these trade-offs potentially affect clinical quality dimensions. Design/methodology/approach The paper is a thematic synthesis of the literature concerning health personnel working in clinical, somatic healthcare services, organizational factors and clinical quality. Findings Identified organizational factors imposing trade-offs were high workload, time limits, inappropriate staffing and limited resources. The trade-offs done by health personnel were often trade-offs weighing thoroughness (e.g. providing extra handovers or working additional hours) in an environment weighing efficiency (e.g. ward routines of having one single handover and work-hour regulations limiting physicians' work hours). In this context, the health personnel functioned as regulators, balancing efficiency and thoroughness and ensuring patient safety and patient centeredness. However, sometimes organizational factors limited health personnel's flexibility in weighing these aspects, leading to breached medication rules, skipped opportunities for safety debriefings and patients being excluded from medication reviews. Originality/value Balancing resources and healthcare demands while maintaining healthcare quality is a large part of health personnel's daily work, and organizational factors are suspected to affect this balancing act. Yet, there is limited research on this subject. With the expected aging of the population and the subsequent pressure on healthcare services' resources, the balancing between efficiency and thoroughness will become crucial in handling increased healthcare demands, while maintaining high-quality care.publishedVersio

Managing the patient safety risks of bottom-up health information technology innovations : recommendations for healthcare providers

Health information technology (IT) offers exciting opportunities for providing novel services to patients, and for improving the quality and safety of care. However, the introduction of IT can lead to unintended consequences, and create opportunities for failure, which can have significant effects on patient safety. In this paper I argue that many health IT patient safety risks are probably quite predictable, but are often not considered at the time. This puts patients at risk, and it threatens the successful adoption of health IT. I recommend that healthcare providers focus on strengthening their processes for organisational learning, promote proactive risk management strategies, and make risk management decisions transparent and explicit