366 Using a Serious Incident and Methods from High Reliability Organisations to Make Communications Safer Between A&E and Surgery

Abstract Aim Healthcare is a high-risk environment and for patients’ safety, requires high reliability. Poor communication one of the leading causes healthcare error worldwide was reasons that led to an adverse event in A&E. High Reliability Organisations (HROs) have set place effective standards safety where probability serious errors very low. What translatable features can make job Junior Surgical Doctor receiving patients from A&E safer? Method The root cause analysis incidence discussed Morbidly Mortality meeting. Focus groups observational studies were carried out over period 6 months. results formed basis Task Analysis. A literature review evidence safe method performed its translatability healthcare. Results “work as done” against imagined” task handover process showed multiple areas potential system” with references SEIPS 101 model. Combining analysis, standardisation (using SBAR), checklist, read-back, dual-modality zone may prove increase redundancy slack system – making it safer. Conclusions There are HRO evidenced methods safer aviation industries “sterile cockpit” “crew management resource” proven effective. Their use above techniques be implemented communication. designated “Handover Zone” could address errors. QI project required hereafter.