Safety by design: a systematic approach to improving safety in the inpatient transfer process

Inadequate handover is a major contributor to patient harm events. Studies to date have predominantly focused on inter-shift handovers. Current knowledge on the nature of handover failures associated with inpatient transfers is scanty. There is also little evidence to support the effectiveness of handover interventions to date. One major barrier is the lack of systematic frameworks to promote rigour in the design and evaluation of interventions.The aims of the thesis are threefold. First, since handover associated with inpatient transfers is poorly understood, the thesis aims to address this existing knowledge gap. The nature and effect of handover failures during this transition of care is explored through three complementary methods: systematic review of literature, analysis of critical incidents, and observational study of inpatient transfers. Second, since interventions to date lack methodological rigour, this thesis explores the feasibility of applying quantitative risk analysis (QRA), adapted from high-risk industries, to evaluate the inpatient transfer process. Fault tree analysis is used to examine the genesis of errors, and reliability analysis is applied to assess process reliability. Finally, the thesis explores the use of signal detection theory (SDT) to evaluate the effectiveness of handover. To achieve these objectives, one specific error is explored in-depth &#150; non-adherence to infection control precautions when transferring an inpatient to radiology. Observations were carried out at a hospital. QRA and SDT were then applied to identify weaknesses in the transfer process. Results of the analyses guided the design of two interventions: (1) a pre-transfer checklist; (2) a coloured cue to highlight infection control information in the transfer form. The interventions were tested in a randomised control trial, and significant improvements in the compliance with infection control precautions were recorded. The use of checklist improved compliance rate from 38% to 71% (p<0.01), and the coloured cue improved compliance rate to 73% (p<0.01). When both interventions were applied, compliance rate reached 74% (p