“Ferrari’s Formula One Handovers and Handovers from Surgery to Intensive Care [Great Ormond Street Hospital for Children]”, 2008-08 ():
De Leval reviewed all the arterial switch procedures done in the United Kingdom over a two-year period with a psychologist watching the operation. Once again, the journey from the operating room to the ICU was demonstrated to be a high risk factor. Staff came to accept that there was an element of danger associated with what they were doing, so they were receptive to change.
Quality Solutions: In Formula One motor racing, the pit stop team completes the complex task of changing tires and fueling the car in about seven seconds. The doctors saw this as analogous to the team effort of surgeons, anesthetist, and ICU staff to transfer the patient, equipment, and information safely and quickly from operating room to ICU.
GOSH doctors visited and observed the pit crew handoff in Italy, noting the value of process mapping, process description, and trying to work out what people’s tasks should be. Following their trip, the GOSH team videotaped the handover in the surgery unit and sent it to be reviewed by the Formula One team. From the analysis came a new handover protocol with more sophisticated procedures and better choreographed teamwork.
The GOSH researchers also noted the importance of the role of the lollipop man, the one who waves the car in and coordinates the pit stop. Under the new handover process, the anesthetist was given overall responsibility for coordinating the team until it was transferred to the intensivist at the termination of the handover. These same two individuals were charged with the responsibility of periodically stepping back to look at the big picture and to make safety checks of the handover.
Results: The real gain for patients was safety. Results showed that the new handover procedure had broken a link between technical and informational errors. Before the new handover protocol, ~30% of patient errors occurred in both equipment and information. Afterward, only 10% occurred in both areas.