Good handovers provide continuity of care and can help to avoid errors, says Medical
Protection’s Dr Ming-Keng Teoh.
When handing a patient over to another doctor for treatment – either between shifts, between phases of care, or between community and hospital care – problems can occur which can put the patient’s safety at risk. The effectiveness of handovers will depend on the timeliness, accuracy and completeness of the information given, and whether it is understood by your colleagues.
Inconsistent processes, absence of best practice guidelines and limited use of protocols mean that handovers can be fraught with risk. Poor handovers can result in adverse events, avoidable harm and complaints. They can be associated with:
- Inaccurate clinical assessment and diagnosis
- Delays in diagnosis and treatment
- Delays in ordering investigations
- Medication errors
- Inconsistent or incorrect translation of results
- Duplication of investigations
- Increased length of stay
- Increased in-hospital complications
- Low patient satisfaction.1
A poor handover can have a significant impact on the quality of care of a patient, and complaints can arise from this. The following risk areas can often contribute to complaints about handovers:
- Lack of clear leadership or responsibility when complications arise
- Failure to effectively communicate a patient’s condition when seeking advice from a colleague
- Inappropriate delegation, for example to a doctor without sufficient expertise
- Lack of an agreed care plan.
Most handovers are done with the best intentions, but quite informally. People are often distracted and trying to do several things at once, which can affect levels of concentration.
A good handover should be a two-way process where information is exchanged and opportunities are given to ask questions and reaffirm that the exchange has been successful. It should be structured and focused on making suitable arrangements for the patient’s medical care, with minimal interruptions.
Checklists can help with the management of common conditions. For example, a successful handover requires:
- A senior clinician to lead the handover
- A shared understanding of the plan of action, who is responsible for each aspect o the patient’s care and exactly what is required
- Designated handover time within working hours (at least 30 minutes for large hospitals)
- Involvement of all relevant health professionals, as more information is needed for high-risk patients
- A clear method of contacting the doctor responsible for a particular patient
- Awareness of potential risks
- Information for the patient as to who will be responsible for their care going forward
Mrs D, a 60-year-old lawyer, was admitted to her local hospital after a short illness characterised by anorexia, vomiting and severe colicky abdominal pain.
She was assessed in the emergency department by Dr L, an emergency medicine doctor. Dr L felt that Mrs D was suffering from sub-acute small intestinal obstruction of uncertain aetiology, but that her condition was not lifethreatening. He thought that Mrs D was stable and suitable for observation and conservative management on a surgical ward. Dr L referred Mrs D to the on-call surgeon, Dr A. The handover was brief, informal and conducted by telephone, as Dr A was in theatre.
Dr A asked Dr L to pass on a message to the ward staff to request that the surgical ward doctor assess Mrs D and pass a nasogastric tube when she arrived on the ward. However, Mrs D was not seen by the surgical ward doctor on her arrival on the ward, as Dr L forgot to impart this information to the nursing staff on the handover form on the front of her notes.
Nor was a nasogastric tube passed. Dr L had requested on the handover form that she have hourly observations and monitoring of her urinary output. Mrs D had her vital signs checked on arrival on the ward but then received no further observations. Six hours after her admission to the ward, a neighbouring patient attracted the attention of a nurse to the fact that Mrs D appeared to be very ill.
Mrs D suffered a cardiac arrest shortly afterwards and could not be resuscitated. A post-mortem revealed a right-sided obstructed, necrotic femoral hernia. Mrs D’s family launched a legal claim against Dr A, Dr L and the nursing staff on the surgical ward, alleging negligence through insufficient assessment and observation.
This case demonstrates the importance of an effective, formalised handover procedure being conducted between departments when patients are admitted to hospital. It resulted in incomplete observations and lacked an ongoing management plan that unfortunately had fatal consequences for Mrs D.
- Jeffcott S A et al, Improving measurement in clinical handover, Quality and Safety in Healthcare (2009)
- Royal College of Surgeons, Safe Handover: Guidance from the Working Time Directive Party (2007)