David Payne: Safe planes and the night handover

David Payne Patient safety conference organisers are fond of the analogy between aviation and medicine. Former F18 pilot Steve Kreister addressed delegates attending the paediatrics day of Risky Business 2010 in London yesterday afternoon.

Airline pilot Martin Bromiley – founder of the Independent Clinical Human Factors Advisory Group (CHFG) – addressed BMJ Group’s Agents for Change conference for junior doctors in May this year.

Two years ago in a BMJ review of Phil Hammond’s To Err is Human radio programme, Robin Ferner asked how useful it is to draw parallels between the two industries. “Plane crashes are extraordinary and dramatic events that happen only if things have gone badly wrong,” he wrote.

“By contrast, some patients inevitably die in hospital. Finding out whether a patient died as the result of an error can be difficult or impossible.

“Although flying is complex, it is now highly automated, and the unexpected is rare. Medicine by contrast has little automation or computerised decision support, and it invites the unexpected.”

Not so, argued Allan Murray in his response to the review: “There are many differences that we rightly need to address, but we need to applaud the airline industry for its reporting, no-blame culture and teamwork, which not so long ago was clearly lacking.”

Bromiley’s interest in human error and health care stems from the death of his wife five years ago after being admitted to a clinic for routine day case sinus surgery. The hospital told him it would investigate his wife’s death only if he sued or complained. He knew that had this been a death in aviation it would have been investigated automatically.

I wonder if speakers at patient safety conferences feel citing the airline industry is obligatory. A morning Risky Business session on changes to the night handover at Great Ormond Street Hospital included a reference to the project team visiting Heathrow Airport’s air traffic control centre, to see how staff there hand over to colleagues at the end of a shift.

But it was only mentioned in passing, and my sense was that the initiative’s success will depend ultimately on its being championed by senior staff, use of the S BAR (situation, background, assessment, recommendation) communication system and the clinical governance tool PDSA (Plan, Do, Study, Act), and regular reviews to check that it’s working. Happily, this seems to be the case .

The new handover process went live in September this year. The hospital was concerned that this crucial point in the working day – when 100s of doctors and nurses hand over to a skeleton staff – could better protect the critically ill children in their care.

Before September the medical handover took place at 8.30pm, the last task of the day for junior doctors, doubtless exhausted after working a 12-13 hour shift. The nurses’ handover happened half an hour earlier, so the medical handover was frequently interrupted by nurses who needed to speak to medical colleagues before they went home.

Jane Carthey, a “human factors” expert who helped to devise then process, told Risky Business delegates the handover was a “baton passing exercise” but the baton was very sick children.  There was no formal system. Discussions were often vague and unfocused, with typewritten notes passed between clinicians. Often the sickest patients were discussed last.

Now the typed sheets are projected onto the wall. The doctors’ mess, where handovers take place, is being refurbished, so the layout is more effective. The night shift  for both doctors and nurses now starts at 8pm.

Before September the mean handover took 34 minutes. It’s now down to 27 minutes. There used to be 7 interruptions on average. Now there are just two. The project team is about to start reviewing the morning handover.

Hopefully next year’s Risky Business will include an update on whether the new morning and night handover systems are working. Perhaps alongside one by representatives from Airbus, Rolls Royce, and Qantas, on how checklists got the grounded A380s back into the air.