Development and validation of a taxonomy of adverse handover events in hospital settings

摘要

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.