Communication between clinicians during a patient handover is a known point of medicolegal risk. Dr Sarah Coope, Senior Medical Educator at Medical Protection, looks at how gaps in information, misunderstandings, and assumptions can increase the risk of errors, conflict, and complaints.
While we can’t have complete control over our patients’ illnesses and disease progression, or the way they respond to interventions, we can take active steps to ensure there is safe continuity of care for the patient at the point of handover and reduce unnecessary adverse events and medicolegal risk.
Imagine you are between appointments on a Friday afternoon. Your colleague calls and he asks if you mind covering for him this weekend as he needs to tend to his elderly parent who has had a fall. He has performed a routine operation on a private inpatient earlier that day and says everything is fine.
How do you respond? Most of us would agree to do this, knowing that these arrangements often need to be reciprocated. However, how do you ensure safe continuity of care as the patient moves across to your care and responsibility, albeit temporarily?
No doubt you would usually ask more questions before ending the call. You would seek to find out more about the patient’s background, to assess if there is any likely risk of complication and establish what the plan is for his discharge. You’d likely check that your colleague has documented this conversation with you in the patient’s records, for medicolegal reasons but also so that ward staff know that you’ve agreed to be contacted if necessary, instead of your colleague. However, would you make a note yourself of the patient’s details, history, and current status, so that you have this information available to remind you now that you’ve taken over responsibility?
For much of the time, despite any weakness in the handover communication and process, these situations pass uneventfully. The patient recovers with no complications and your colleague takes over their uneventful care again on Monday morning.
However, there are inevitably occasions when this is not the case. You accept a handover from a colleague, either a cover arrangement such as this, or agree to give a second opinion, arrange an admission, or transfer of your patient, and then things go wrong as they move between care providers.
Sometimes this is due to complications arising that you couldn’t have foreseen, but other times analysis of adverse outcomes indicates that communication failure between colleagues around the time of the handover is frequently the root cause.1,2 For example, a significant underlying condition isn’t mentioned, a drug is missed off their transfer sheet, or a key abnormal observation or result isn’t alluded to. And not having this information may lead to poor decision-making or suboptimal management.
If there is a communication gap, safe and effective care of the patient can easily fall through, leading to possible adverse events and increased risk of claims or complaints.
Often several health professionals are involved in a typical patient’s care journey, eg from the GP to consultant specialist, radiologist, theatre and ward staff, pharmacist, physiotherapist, and back to the GP. With more people involved, there is a greater chance of there being miscommunication and errors at some point along the way.
Many conversations about patient care with our colleagues take place over the phone rather than in-person. Remote communication can exacerbate the existing risks further, primarily due to a lack of visual and non-verbal information in the interaction. The oft-stated phrase “words make up only 7% of your message” resonates here. Aside from the content of your spoken words, the other 93% of the communication comes from the style of delivery. This includes the speaker’s body language, tone of voice, and attitude – all of which convey crucial meaning, however much of this is missing on the telephone. And what is said, is therefore more open to misinterpretation. So, particularly for complex cases, discussing the patient over a video call might be a less risky option to consider if face to face isn’t possible.
Common causes of weak links and gaps
What stops us from transmitting key information when referring a patient, or ensuring that we’ve received all the facts we need to know when accepting a handover remotely?
There are in fact a range of factors affecting either the quality of the interaction or the information.
• Those affecting the quality of the interaction include:
• Barriers in access to, availability, and approachability of colleagues
• Unstable connection and signal if using a mobile device
• High level of external interruptions, distractions, and time pressure
• Existing dysfunctional relationships and lack of trust
• Reluctance to take responsibility
These are not always easy to eliminate or resolve, but it is helpful to be aware of them and compensate where possible by consciously strengthening the factors that you can address.
Those factors affecting the quality of the information obtained include:
• Inadequate preparation before the call
• Lack of relevant facts about the patient’s situation, current status, or background
• Missing details about the care received so far
• Unclear message, agenda, or request
• Lack of confidentiality or privacy when taking the call
• Not building a positive connection or rapport
• Ignoring verbal cues
• Abrupt or dismissive manner
• Interrupting or talking over
• Assumptions about a colleague’s level of knowledge and skill
• Not clarifying areas that are ambiguous
• Not speaking up or challenging potentially suboptimal decisions
Strengthening the communication of the transition conversation
All of the potential weak links mentioned above are important. However, the key thing to focus on is ensuring that adequate, relevant information is included in a handover so that it is as complete and safe as possible.
A framework can be helpful to have in the forefront of your mind, to aid preparation before making a call, or during accepting a patient. You may already be familiar with the ISBAR3 model (see below).3 It is widely used in clinical settings, although initially developed by Dr Michael Leonard for the US Military to assist with safe communication on nuclear submarines. At Medical Protection, we have also developed another model for safe transfer of patient care which we teach in our ‘Mastering Professional Interactions’ workshop.
I – identify
Identify yourself and the site/unit you are calling from
Identify the recipient’s name and role
Identify the patient by name
S – situation
State the location of the patient as appropriate
Give a brief summary of the patient’s current status
Describe your concern and reason for the call
B – background
Give the patient’s reason for admission
Explain significant medical history
Inform the receiver of the information of the patient’s background: admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results, and other relevant diagnostic results
A – assessment
Trajectory of the patient’s condition
Clinical impressions, concerns
You need to think critically when informing the receiver of your assessment of the situation. This means you have considered the possible underlying reason for your patient’s condition. Not only have you reviewed your findings from your assessment, but you have also consolidated these with other objective indicators, such as laboratory results.
R3 – recommendation, risk, and read-back
That is, what you would like to happen by the end of the conversation. Any advice that is given on the phone needs to be repeated back to ensure accuracy.
• Explain what you need – be specific about request and time frame
• Make suggestions
• Clarify expectations. Have clear agenda/request/purpose – include concerns/fear about what’s likely to happen.
• State any additional relevant risks that the recipient may need to be aware of, eg falls risk, visual impairment, similar name to another patient on the unit
• Check that the message you have sent has been accurately received by asking the recipient to ‘read-back’ the information.
So, how strong are your remote interactions with colleagues in these situations? Next time you pick up the phone to accept or make a patient handover, put yourself in the shoes of the patient’s journey and aim to build a safe, solid structure into your communication.
By reflecting on this and making changes to the way that you present or receive vital information about a patient, you can fill in the gaps, strengthen the connection, increase the chance of a smooth transition of care, and mitigate the associated medicolegal risk.
1Joint Commission on Accreditation of Healthcare Organizations. The Joint Commission guide to improving staff communication. Oakbrook Terrace, IL: Joint Commission Resources; 2005
2Beckman HB, Markakis et al. "The doctor-patient relationship and malpractice: Lessons from plaintiff depositions”. Archives of Internal Medicine 1994; 154: 1365-1370
3Improvement.nhs.uk SBAR communication tool