Dropping the baton

Handovers are ubiquitous, cutting across all disciplines, specialties and clinical settings. This makes them potentially dangerous if they are done poorly, says Sara Williams

Last year, Australia was shaken by the case of a 78-year-old frail Aboriginal man called Peter Limbunya, who was discharged from Katherine Hospital in the Northern Territory and flown, with no escort, to an isolated airstrip some distance from his home at Kalkaringi and left alone to die, as a result of a catalogue of poor handovers.

Peter had been evacuated to hospital with pneumonia.¹ When he was discharged eight days later, his paperwork was faxed to the community health centre in Kalkaringi on a Friday, advising them of his scheduled Monday discharge. However, the fax was not seen, so the community health centre was not aware of Peter’s return.

There was no checking system to confirm that the discharge paperwork had been received; the hospital assumed that the fax would be acted on and someone would be there to collect Peter from the airfield when he was dropped off, which was far from his home. In reality, no-one was aware of his return. He tried to walk home but was found dead from pneumonia and dehydration three days later, only 400 metres from the airstrip.

Unseen in day-to-day practice, handovers are in the spotlight when things go wrong; they are essential in providing continuity of care and error avoidance.

Following this tragic case, the Northern Territory government took steps to improve its handover procedures. Furthermore, the World Health Organisation (WHO) Patient Safety Alliance designated Australia as the lead country to implement standardised solutions to improve clinical handovers, as part of the “High 5s” Initiative.²

Australia may be a vast country without parallel, but lessons can be learnt from Peter’s case that can be mirrored in cases all over the world. For example, an elderly patient may be dropped off after receiving treatment; unbeknown to the hospital, but known to the GP, they live 13 stories up. The day they are dropped off the lift is broken – how would the patient get home?

An Australian doctor in 2005 summed up the state of handovers in his hospital as “unstructured, informal and error prone, with the majority of doctors noting that there is no standard or formal procedure for clinical handover”.³ How many doctors across the world would make a similar observation?

What is a good handover?

A definition of a clinical handover, developed by the UK-based National Patient Safety Agency (NPSA), has been used across the world: “The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or a permanent basis.”⁴

In the UK, the GMC says: “You must be satisfied that, when you are off duty, suitable arrangements have been made for your patients’ medical care. These arrangements should include effective hand-over procedures, involving clear communication with healthcare colleagues.”⁵

Dropping the baton

There are lots of occasions in clinical practice where information has to be handed over. The effectiveness of this will depend on the accuracy and completeness of the information, and whether it is received clearly and understood by the recipient. The lack of consistent processes, the absence of best practice guidelines and the limited use of protocols mean that handovers are fraught with risk. Poor handovers create discontinuities in care that can lead to adverse events and subsequent litigation.

Poor handovers are associated with: 

• inaccurate clinical assessment and diagnosis 
• delays in diagnosis 
• delays in test ordering
• medication errors 
• inconsistent or incorrect results translation 
• duplication of results 
• increased length of stay 
• increased in-hospital complications 
• decreased patient satisfaction.⁶

A New Zealand study of clinical handovers in a tertiary hospital found that the majority of house officers encountered a clinical problem due to poor handover between seven and 14 times in their previous three-month rotation. This was put down to inadequate systems, poor leadership and lack of specific handover locations.⁷

Professor Charles Vincent, from Imperial College in London, has spent 20 years studying patient safety. He argues that you can learn from handover mistakes.

"When things go wrong, it’s what I call a window on the system: it exposes areas of vulnerability in the process. If something happens to a patient because information was not handed over, the question to ask is: was this a one-off or are we handing information over badly?”

MPS has seen a number of claims arising from poor handovers; for example, from a GP to a consultant (and vice versa), within a hospital (between a consultant and various doctors), and between A&E and the ward.

Medicolegal principles and handovers

An American study of malpractice claims suggests that the risks associated with handovers are far-reaching, in terms of adverse outcomes and the financial cost of subsequent litigation.⁸ Among 240 negligence claims, where trainees were judged to have played a moderately important role, teamwork breakdowns accounted for 167 of the contributing factors (70%). The most prevalent teamwork problems were the lack of supervision and ineffective handover; both were disproportionately common among the errors.

MPS has seen a sustained rise in litigation surrounding handovers. A review of handover claims revealed the following risk areas:

• existence of multiple verbal and written contact points between service providers 
• failure to effectively communicate a patient’s condition when seeking advice 
• incomplete or unclear handover of accountability 
• lack of an agreed care plan 
• variable or overlapping formats of written communication.

Hospital handovers

In Europe this year, the European Working Time Directive (EWTD) came fully into force. It was designed to prevent doctors working excessive hours, and has placed a limit of an average of 48 hours worked by doctors per week. The EWTD has posed major challenges to the way care is delivered. Continuity of care has been disrupted and handovers have increased.

According to Elwyn Eastlake, MPS’s executive officer in New Zealand, the success of getting working hours down for junior doctors in New Zealand has led to more handovers, so the more handovers you have the more problems you get.

In the UK last October, the Royal College of Surgeons published its own survey on the effects of the EWTD.9 A third of the doctors surveyed said that handover arrangements were inadequate in their hospital.

Dr Maisse Farhan is an emergency medicine consultant at St Mary’s Hospital in London. She has completed research into how end-of-shift handovers can affect patient safety. “A good end-of-shift handover should encompass clinical and organisational issues, communicating any problems encountered during the previous shift. This would enable the oncoming doctors to anticipate problems as they arise.

“A really bad handover is one that does not happen; I have experienced this throughout my career – you arrive for a new shift and the night doctor has gone home. Another example of a poor handover is one where a list of patients is handed over, consisting of names and a diagnosis. This would contain no indication of clinical prioritisation or acuity of the patients.”

In the emergency department, poor handovers can lead to adverse events where investigations or treatment are delayed. Miscommunication or misunderstanding during individual patient handover may lead to completely the wrong treatment being instituted or, for example, the patient being discharged incorrectly.

Professor Vincent likens handovers to Chinese whispers. “A colleague of mine has been tracking surgical patients, and there are multiple times when information is transferred down the pathway. A message starts in one form; it is then relayed from one person to another and so on – gradually changing.

“Most handovers in healthcare are done with the best intentions, but quite informally. Often people are distracted and trying to do several things at once; when this happens, it is difficult to concentrate on what people are telling you. I’ve observed handovers that people have monitored to see if essential information has gotten across, but found that many things were left out. This is not down to people being deliberately sloppy, but because the pressure of events makes it hard to get the information across reliably.”

Improving hospital handovers

Dr Farhan has recently introduced a new system at St Mary’s Hospital for end-of-shift handover in the emergency department to standardise and improve handovers.

“My research identified a new method for end-of-shift, which was implemented and tested and resulted in practice change for end-of-shift handover. The principles behind the work are to use handover to trigger proactive problem-solving rather than being reactive to problems after they have arisen.”

According to Dr Farhan, under her system, end-of-shift handover follows a standard structure using different headings – a mnemonic that means less variability between doctors and less likelihood for human factors, such as tiredness, to affect the quality of the information transfer.

“There are so many variables that can affect the success of a handover at the end of a shift: your level of experience, your skills in communicating with others, your ability to understand and react to the environment surrounding you, the type of experiences and events that have occurred during the course of the day, the personal interaction and dynamics of a team, and finally your personal maturity. I believe that standardising handovers reduces this variability because it provides a platform that even locum doctors who may be unfamiliar with the hospital setup can utilise.”

Making staff at St Mary’s more aware of the importance of handovers has changed their attitudes; they are now more rigorous and conscientious about getting the information across, thus reducing the likelihood of error.

But Professor Vincent argues that although standardised processes have their benefits, it is important that different specialties adapt their own systems.

“We can learn from other specialties, whether it be pilots, nurses or other doctors; it is more about customising the handover to the people involved.

“The handover from theatre to intensive care for heart surgery patients would be very controlled, compared to a handover in a ward, where you’ve got more than 20 patients. You’d be much more reliant on a structure that allows people to say: ‘Here is the routine information, but these are the patients we are really worried about.’ You have to think about what the handover is for, what the purpose is and what information is needed.”

Hospital initiatives

The principles behind Dr Farhan’s work are similar to those behind the “Hospital at Night” project (HaN) in the UK. It’s designed to make the most efficient use of time through better communication and multi-disciplinary teamwork based on competence rather than the grade of staff, targeted to pick up patients that are sick before they become sick. The approach has been so successful that other countries are adopting similar models.¹⁰

Unfortunately, there is no validated method of assessing teamwork, but medical simulation training can offer ways of evaluating handover effectiveness. An Australian study deployed a tool, HELiCS (Handover – Enabling Learning in Communication for Safety), which uses a “video-reflexive” technique, to record real-life handovers.¹¹

Conceptually, it enables clinicians to move from reflection on action to reflection in action, ie, the ability to scrutinise an action at the time of carrying it out.

Using these techniques, staff of an emergency and an intensive care department (details of which were anonymised) were able to articulate the practical contingencies that enable and constrain their practices, and redesign their handover processes. The emergency department developed what they called the "twice-daily bedside nursing-medicine team leader ward round”.

The intensive care unit developed improvement strategies including: 

• a bedside nurse who would initiate the handovers to the medical team 
• medical shift handovers occurring at the patient’s bedside, to obviate misidentification and link handover information to up-to-date patient observation.

Quick guide to handovers

• Begin with a short briefing – “situational awareness” 
• Facilitate a structured team discussion 
• Establish and develop contingency plans – “what to do if…” 
• Encourage questions from the team – there are no “stupid questions”
• As a minimum, ensure the following is imparted: 
  • Patient name and age 
  • Date of admission 
  • Location (ward and bed) 
  • Responsible consultant 
  • Current diagnosis 
  • Results of significant or pending investigations 
  • Patient condition 
  • Urgency/frequency of review required 
  • Management plan, including “what if…” 
  • Resuscitation plan (if appropriate) 
  • Senior contact detail/availability 
  • Operational issues, eg, availability of intensive care unit beds, patients likely to be transferred 
  • Outstanding tasks.¹²

General practice handovers

Dr Paul Nisselle is Senior Consultant in MPS’s Educational Services department. Starting medical life as a GP, he worked for medical protection organisations in Australia for more than 20 years before taking up his present appointment. He likens handovers to baton-changing in relay races.

“A successful baton change requires that the baton not only be in the other person’s hand, it must also be firmly grasped and taken cleanly from you. Think of the Melbourne Commonwealth Games, where the English team dropped the baton at the last change and lost the race.

“For GPs, it is easy to say that all the information is in the notes, but if there are patients in midair when you go on holiday or finish working at a practice, etc, it makes sense to call attention to these patients. Also, medical regulators take a hard line on failure of follow-up. If a test is important enough to be ordered, then it is important enough to have a system in place to make sure that the result is seen and is acted upon.”

Handover pitfalls in primary to secondary care

• Missed referrals – GP decides a referral is warranted but forgets to make it.
• Inappropriate degree of urgency – the symptoms fit the criteria for a two-week rule referral, but the patient is referred on a routine basis so diagnosis is delayed. 
• Introduction of referral management centres – it is no longer possible to refer to a named consultant and referral letters may not be screened by a clinician, so a further safeguard against inappropriately categorised referrals has been lost. 
• Missing information – GP omits important information from the referral letter, such as drug allergies, important past history, etc. 
• OOH services – incorrect exchange of information.

Handover pitfalls in secondary to primary care

• Delay – where there is an unacceptable delay in the provision of important clinical information, such as changes in treatment regimes, follow-up arrangements and new diagnoses. 
• Appointment letters sent to the wrong address – a GP receives a DNA letter, and treatment is delayed. 
• Information not reaching the practice – test results sent to the wrong practice. 
• Incomplete information sent to the practice – in a recent case, a GP ordered three x-rays, one of which was a chest x-ray. Only two x-ray results were returned and both were reported as normal; the chest x-ray showed evidence of a bronchial carcinoma, but was not returned. The patient called for their x-ray results and was told they were normal. It was several months before the error was noted. Such risks can be minimised by receptionist training, informing patients what tests have been taken, recording all tests as they are ordered AND having a system to check whether a result has been received for all tests ordered.

Handover pitfalls within primary care

• Visit requests not passed to the GP – either at all or with an inappropriate level of urgency. 
• Abnormal test results not being acted upon – eg, when a GP partner is on leave or abnormal results being ticked and filed in error. 
• Communicating test results to patients – this task is often delegated to a receptionist who may not be appropriately trained to give out results. 
• Continuity of care – it is not uncommon for complaints to arise when a patient has seen several members of the practice team with the same problem and no-one has taken charge of its management.

Conclusion

Last year, an American professor used a musical analogy to explore the pitfalls of handovers.¹³ Recalling the teachings of Claude Debussy – “Music is not just about the notes…it is created by the spaces between the notes” – he argues that successful healthcare requires attention to effective connectivity between every component – the spaces between the notes. If attention was spread more evenly across the whole process and people began thinking outside their particular box, cases like Mr Limbunya’s would not occur.

Thanks to Dr Richard Stacey and Dr Sheena McMain for their help with this article.

References

1. Northern Territory Magistrates Courts. Inquest into the death of Peter Limbunya. Darwin, NTMC 057, 2008.

2. World Health Organisation. Action on patient safety – High 5s, (2009)

3. Bomba DTPR. A description of handover processes in an Australian public hospital, Australian Health Review (2005)

4. NPSA, Safe handover: Safe patients, BMA (2004)

5. GMC, Good Medical Practice (2006) par 48

6. Jeffcott, S A. et al. Improving measurement in clinical handover, Quality and Safety in Healthcare (2009)

7. McCann, L et al. Passing the buck: Clinical Handovers at a New Zealand Tertiary Hospital, NZMJ (2007)

8. Singh, H et al. Medical Errors Involving Trainees, Archives of Internal Medicine, USA (2007)

9. Royal College of Surgeons, EWTR Summary of Responses to College Survey, (2009)

10. Department of Health. The Implementation and Impact of the Hospital at Night Pilot Projects: An evaluation report, London (2005)

11. Iedema, R and Merrick, E et al. Handover – Enabling Learning in Communication for Safety (HELiCS: A report on achievements at two hospital sites, MJA (June 2009)

12. Royal College of Surgeons of England, Safe Handover: Guidance from the Working Time Directive Party (2007)

13. Stevens, D P. Handovers and Debussy, Qual Saf Health Care USA (2008).