Proposed Topic (Most preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service III (Projects aiming at quality service to patients and their carers)
Authors (including presenting author) :
Mok YT(1), Dr Yuen MYV(1), Law NW(1), Chu WL(1), CH Wong(1)
Affiliation :
(1)Department of Anaesthesiology and Perioperative Medicine, Hong Kong Children’s Hospital
Introduction :
Introduction
Effective handover procedures are crucial to patient safety. Unfortunately, a critical incident related to handover occurred in the post-anaesthesia care unit (PACU0 of the Hong Kong Children’s Hospital (HKCH). Factors such as complex clinical, cultural, behavioral and environment elements have negatively impacted inter-professional handover communication and team performance. PACUs, being high-risk areas where vulnerable patients are transferred from the operating room after anaesthesia for immediate post-opeartive care, require meticulous handovers form anaesthesiologists to receiving nurses.
To address this issue, HKCH has implemented the use of the clinical information system (CIS) as a platform for handover procedures in the PACU. The nursing and anesthetic teams utilize the CIS, employing an electronic checklist that allows staff to manage handovers seamlessly.
Objectives :
The objective of this project was to implement the 3s handover system at PACU to promote safe and team approach handover.
Methodology :
1. Analyze of critical incident report relating to PACU clinical handovers.
2. Review Process of clinical handover. Four definable stages in the process of clinical handover in PACU were identified: -
Connection of patients to monitoring and support equipment;
Observation and immediate care for patient safety;
Listening during verbal exchange of patient information; and
Delegation of responsibility using discussion, clarification and checklists.
3. Identify need: Multiple data sources provided a rigorous way to identify and understand the critical steps and behaviors that contribute to patient safety during PACU handovers. A simple tool to reduce clinical risk by standardizing complex inter-professional clinical handover in PACU.
4. Implementation of handover procedure:
Seamless: A user-friendly and structural checklist on CIS for enhancing communication and ensuring continuity of care.
Same Page: a protective time for completion of a checklist upon patient’s arrival. Verbally confirmation of 3 parties became compulsory.
Systematic clinical handover: Easy to follow checklist for new, frontline and junior staff.
Result & Outcome :
100% of Anaesthetist and Nurses working in HKCH agreed this standardised tool can enhance communication, teamwork and patient-care outcomes, and reduce clinical risk. No similar critical incidents were occurred after commencement of it. Similar actions will provide a useful approach for minimizing the risk of communication errors during PACU handovers.
