#20 2003 · Great Ormond Street Hospital × Ferrari · Motorsport → surgery
A children's hospital hired Ferrari's pit crew to redesign how patients change hands
the problem
Errors clustered in the surgery-to-ICU handover
background
Moving a child from open-heart surgery to intensive care meant a dozen people — surgeons, anaesthetists, perfusionists, ICU staff — converging around one bed at once, each handing off a different piece of the patient's state with no fixed order or assigned roles. Technical errors and dropped information clustered exactly there, in the changeover, not in the surgery or the ICU stay either side of it.
Cardiac surgeon Martin Elliott and consultant Allan Goldman were watching a Formula 1 broadcast in the staff room in the early 2000s when they had the same thought at the same time: a pit crew changes four tyres and refuels a car in under seven seconds with zero ambiguity about who does what. They arranged for the hospital team to study a Ferrari pit stop directly, and for the pit crew to watch a hospital handover in return.
the move
Surgeons watching F1 pit stops asked Ferrari's crew to redesign the surgery-to-ICU patient handover: defined roles, a leader, a rehearsed sequence.
the payoff
Published follow-up found technical errors per handover fell by around 40%.
what came after
The team, led by human factors researcher Ken Catchpole, published the results in Pediatric Anesthesia in 2007. Accounts of the exact improvement vary by which measure is cited — one summary reports a 66% reduction in handover errors overall, another that the share of handovers with combined equipment-and-information errors fell from roughly 30% to roughly 10% — but every account agrees the redesigned, choreographed handover measurably outperformed the ad hoc one. The study became a reference case for applying human-factors research from aviation and motorsport to clinical handoffs, cited widely in patient-safety literature since.
filed under
references
- [1]Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and qualityPediatric Anesthesia (Wiley), 2007onlinelibrary.wiley.com
- [2]Great Ormond Street Hospital for Children: Ferrari's Formula One Handovers and Handovers from Surgery to Intensive CareAmerican Society for Quality, 2009asq.org