METHODS: A prospective intervention study measured the change in performance before and after the implementation of a new handover protocol that was developed through detailed discussions with a Formula 1 racing team and aviation training captains. Fifty (23 before and 27 after) postsurgery patient handovers were observed. Technical errors and information omissions were measured using checklists, and teamwork was scored using a Likert scale. Duration of the handover was also measured.
RESULTS: The mean number of technical errors was reduced from 5.42 (95% CI +/-1.24) to 3.15 (95% CI +/-0.71), the mean number of information handover omissions was reduced from 2.09 (95% CI +/-1.14) to 1.07 (95% CI +/-0.55), and duration of handover was reduced from 10.8 min (95% CI +/-1.6) to 9.4 min (95% CI +/-1.29). Nine out of twenty-three (39%) precondition patients had more than one error in both technical and information handover prior to the new protocol, compared with three out of twnety-seven (11.5%) with the new handover. Regression analysis showed that the number of technical errors were significantly reduced with the new handover (t = -3.63, P < 0.001), and an interaction suggested that teamwork (t = 3.04, P = 0.004) had a different effect with the new handover protocol.
CONCLUSIONS: The introduction of the new handover protocol lead to improvements in all aspects of the handover. Expertise from other industries can be extrapolated to improve patient safety, and in particular, areas of medicine involving the handover of patients or information.
方法:一项前瞻性干预研究测量了在实施新的移交协议之前和之后的表现变化,该协议是通过与一级方程式赛车队和航空训练队长的详细讨论而开发的。观察到50例(手术前23例和手术后27例)患者交接。使用检查表衡量技术错误和信息遗漏,团队合作是用李克特量表评分的。还测量了切换的持续时间。
结果:技术错误的平均数从5.42(95%CI+/-1.24)减少到3.15(95%CI+/-0.71),信息移交遗漏的平均数量从2.09(95%CI+/-1.14)减少到1.07(95%CI+/-0.55),并且切换持续时间从10.8min(95%CI+/-1.6)减少到9.4min(95%CI+/-1.29)。在新方案之前,23名患者中有9名(39%)在技术和信息移交中出现了一个以上的错误。相比之下,新交接的三分之二(11.5%)。回归分析显示,新交接技术错误数量显著减少(t=-3.63,P<0.001),并且交互表明,团队合作(t=3.04,P=0.004)对新的切换协议有不同的影响。
结论:新的切换协议的引入导致切换的所有方面的改进。可以推断其他行业的专业知识,以提高患者的安全性,特别是,涉及患者或信息移交的医学领域。