Abstract
To develop and validate a taxonomy to classify and support the analysis of adverse events related to patient handovers in hospital settings. A taxonomy was established using descriptions of handover events extracted from incident reports, interviews and root cause analysis reports. The inter-rater reliability and distribution of types of handover failures and causal factors. The taxonomy contains five types of failures and seven types of main causal factors. The taxonomy was validated against 432 adverse handover event descriptions contained in incident reports (stratified random sample from the Danish Patient Safety Database, 200 events) and 47 interviews with staff conducted at a large hospital in the Capital Region (232 events). The most prevalent causes of adverse events are inadequate competence (30 %), inadequate infrastructure (22 %) and busy ward (18 %). Inter-rater reliability (kappa) was 0.76 and 0.87 for reports and interviews, respectively. Communication in clinical contexts has been widely recognized as giving rise to potentially hazardous events, and handover situations are particularly prone to failures of communication or unclear allocation of responsibility. The taxonomy provides a tool for analyzing adverse handover events to identify frequent causes among reported handover failures. In turn, this provides a basis for selecting safety measures including handover protocols and training programmes.
Highlights
In recent years, there has been an increased focus on patient safety during patient handovers
The taxonomy was validated against 432 adverse handover event descriptions contained in incident reports and 47 interviews with staff conducted at a large hospital in the Capital Region (232 events)
Several studies have shown that handovers are associated with adverse events (Arora et al 2005; Pezzolesi et al 2010; Cohen and Hilligoss 2010) and initiatives have recently been launched to reduce adverse events associated with handovers, including an extensive programme introduced by the Australian Commission on Safety and Quality in Healthcare to develop and improve clinical handover communication (ACSQHC 2011)
Summary
There has been an increased focus on patient safety during patient handovers. Several studies have shown that handovers are associated with adverse events (Arora et al 2005; Pezzolesi et al 2010; Cohen and Hilligoss 2010) and initiatives have recently been launched to reduce adverse events associated with handovers, including an extensive programme introduced by the Australian Commission on Safety and Quality in Healthcare to develop and improve clinical handover communication (ACSQHC 2011). The WHO Patient Safety Alliance has identified communication failures during patient handovers as well as medication accuracy at transitions in care as part of its High 5-s initiatives (WHO 2007). The study reported in this paper has aimed at developing and validating taxonomy to support the analysis and classification of adverse events related to patient handovers.
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