Review: bringing patient safety to the forefront through structured computerisation during clinical handover

Aims and objectives. This review aims to examine critically, the methods and modes of delivery of handover used in contemporary health care settings and explore the feasibility of a computerised handover system for improving patient safety. Background. Clinicians play a critical role in promoting patient safety, and the handover ritual is recognised as important inexchanging information and planning patient care. Communication failures have been identified as an important cause ofadverse incidents in hospitals. Design. Integrative literature review. Methods. Search of multiple electronic databases using terms: nursing handover, handoff, shift-to-shift reporting and change ofshift report. Discussion. To date, the focus of research has primarily been on the vehicle of the handover, rather than the content andprocesses involved in ensuring the reliability and quality of clinical information. Employing a computerised handover system inthe clinical arena has the potential to improve the quality and safety of clinical care. Conclusions. Whilst the handover performed from shift-to-shift is a valuable communication strategy, ambiguities and incomplete information can increase the risks of adverse events. Given the importance of effective communication, its key linkto patient safety and the frequency of nursing handover, it is imperative that clinical handover undergo increased scrutiny, development and research. Relevance to clinical practice. This review underscores the challenge in clinical handover and recommends the use of technological solutions to improve communication strategies

The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management

The increasing complexity of modern radiation therapy planning and delivery challenges traditional prescriptive quality management (QM) methods, such as many of those included in guidelines published by organizations such as the AAPM, ASTRO, ACR, ESTRO, and IAEA. These prescriptive guidelines have traditionally focused on monitoring all aspects of the functional performance of radiotherapy (RT) equipment by comparing parameters against tolerances set at strict but achievable values. Many errors that occur in radiation oncology are not due to failures in devices and software; rather they are failures in workflow and process. A systematic understanding of the likelihood and clinical impact of possible failures throughout a course of radiotherapy is needed to direct limit QM resources efficiently to produce maximum safety and quality of patient care. Task Group 100 of the AAPM has taken a broad view of these issues and has developed a framework for designing QM activities, based on estimates of the probability of identified failures and their clinical outcome through the RT planning and delivery process. The Task Group has chosen a specific radiotherapy process required for “intensity modulated radiation therapy (IMRT)” as a case study. The goal of this work is to apply modern risk-based analysis techniques to this complex RT process in order to demonstrate to the RT community that such techniques may help identify more effective and efficient ways to enhance the safety and quality of our treatment processes. The task group generated by consensus an example quality management program strategy for the IMRT process performed at the institution of one of the authors. This report describes the methodology and nomenclature developed, presents the process maps, FMEAs, fault trees, and QM programs developed, and makes suggestions on how this information could be used in the clinic. The development and implementation of risk-assessment techniques will make radiation therapy safer and more efficient