Clinical Handover: what are the risks?

The CAREFUL view of Clinical Handover

Handover involves the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or groups of patients, to another person, or professional group on a temporary or permanent basis1.

This can include:

  1. peer-to-peer handover, usually at shift end;
  2. internal referrals between teams for the purpose of shared care or consultation; and
  3. transfers between institutions or discharges resulting in a change in setting.

All of these can also be considered as transitions of care and are subject to similar risks.

What’s the evidence that handover is risky?

There is considerable research and evidence that indicate that poor handover results in significant morbidity, mortality, dissatisfaction, and excess financial costs.

A study from 2008 showed communication breakdowns were a contributing factor in 43 percent of incidents, and two-thirds of these communication issues were related to issues with handover2.

It has been reported that the Agency for Healthcare Research and Quality (AHRQ) in the USA estimates 70% of deaths caused by medical errors are related to communication breakdown during handover3.

Problems with communication between caregivers during patient transfer may play a role in an up to 80% of serious preventable adverse events4.

Communication failures in American hospitals and medical practices account for at least 30% of malpractice claims, which resulted in over $7 billion of financial loss over 5 years5. Issues with handover can also cause unnecessary prolongation of hospital stays and significant harm as a result6-8.

Handover is a critical process yet is often undertaken in a haphazard fashion, with the method and extent of information transferred varying considerably9.

What does this mean?

The frequency of handover in healthcare settings is high; an estimated 4,000 handovers occurring each day in a typical teaching hospital10. Taken together, the evidence indicates that handover is the source of multitude of errors and the cause of much harm11.

Despite its high-risk nature, little formal attention, education and evaluation is given to handover12. The problem has recently been receiving more recognition. The World Health Organization (WHO) has highlighted transitions of care as part of the 2021-2030 safety strategy13. The UK General Medical Councils (GMC) emphasises the need to “keep colleagues well informed when sharing the care of patients”14 and importance of employing a standardised handover approach is emphasised by the Accreditation Council for Graduate Medical Education (ACGME) and the Joint Commission on Accreditation of Healthcare, which have included competency in patient handover as a necessary requirement for residency training and hospital quality standards15.

Despite this, there is a paucity of evidence on the opinions of practitioners on the safety of handover and transitions of care, which is why we undertook the research on this.

A visual analogy

As a strongly visual analogy, this clip demonstrates how dangerous the point of handover can be.

Where do handover risks originate from?

There are a number of sources of risk in clinical handover:

– Communication failures: handover is a critical time for communication between caregivers, and errors can easily occur if information is not properly transferred.

– Misinterpretation of information: handover is also a time when information is passed between caregivers, and there is a risk that it will be misinterpreted or not properly understood.

– Fatigue and stress: handover is often an intense, busy time when clinicians are at their most tired, which can lead to mistakes being made.

– Lack of standardisation: handover can vary significantly from one situation to another or between teams or even individuals. Again it is lack of structure and process which makes the event vulnerable to error.

What are the consequences of poor handover?

Poor handover can have a number of serious consequences, including:

– Errors in treatment: There are a number of different types of error. Aside from gross errors or complete blunders there are a variety of other ways that treatment can be sub-optimal. More detail on errors can be found here.

– Prolonged hospital stays: poorly structured or informal handover is often rushed and done in a haphazard fashion, which can lead to confusion and errors. This causes patients to stay in hospital longer than necessary due not only to delays but increased morbidity as well.

– Patient dissatisfaction: handover is often seen as a stressful and chaotic process, and it can lead to patients feeling dissatisfied with their care.

– Medical errors: handover is a high-risk process and can lead to mistakes being made that can result in serious harm to patients.

How to improve improper handover

There are a number of ways to improve handover and reduce the risk of errors. Some suggested measures include:

– Introducing standardised handover procedures

– Training healthcare workers in handover procedures

– Improving communication between caregivers

– Reducing stress and fatigue among healthcare workers

– Encouraging caregivers to ask questions during handover

– Ensuring that all relevant information is passed on during handover

– Checking to see that patients have been properly transferred at the end of handover.

Why is ATMIST important in handover?

Use of ATMIST is advised wheneverhandoveris being given to an ambulance crew. The five letter acronym summarises age (demographics), time, mechanism, injuries (exam findings), (vital) signs and treatment given.

ATMIST is a handover tool that helps to quickly and accurately transfer patient information between caregivers. Many NHS ambulance services and hospitals now promote the use of ATMIST in patient handover situations, as it facilitates a rapid, accurate handover.

It also significantly improves communication with medical practitioners, ambulance crews and emergency departments and helps to ensure that all relevant information is passed on during handover.

The UK Resus council guidelines suggest use of ATMIST.

What is SBAR?

SBAR is the more commonly used handover acronym within hospitals, often used by nursing staff and doctors to formalise the process.  

SBAR is another handover tool that helps to quickly and accurately transfer patient information between caregivers. SBAR stands for Situation, Background, Assessment and Recommendation, and it provides a simple framework so that handover details are homogenous and predictable.

More information

See: https://careful.online/handover-is-dangerous-10-things-we-learned-about-patient-safety/ 

You can download the full paper here: https://www.preprints.org/manuscript/202205.0202/v2 

References

1.       Merten H, van Galen L, Wagner C. Safe handover. BMJ. 2017;j4328.

2.       Gawande AA, Zinner MJ, Studdert DM, et al. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133:614–621.

3.       Van Wegenen J. Cloud-Based Tools, Software Cut Down on Clinical Handoff Errors. HealthTech [Internet]. 2017 [cited 27 April 2022]. Available from: https://healthtechmagazine.net/article/2017/08/cloud-based-tools-software-cut-down-clinical-handoff-errors

4.       Sentinel Event Statistics Released for 2015. (2016). Joint Commission perspectives. Sentinel Event Statistics Released for 2015. Joint Commission perspectives Joint Commission on Accreditation of Healthcare Organizations [Internet]. 2016 [accessed 26 April 2022];36(4):10. Available from: http://info.jcrinc.com/rs/494-MTZ-066/images/Sentinel39.pdf

5.       Medication-related Malpractice Risks: CRICO 2016 CBS Benchmarking report [Internet]. Harvard: The Risk Management Foundation; 2016 [cited 26 April 2022]. Available from: https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Medication

6.       Lofgren R, Gottlieb D, Williams R, Rich E. Post-call transfer of resident responsibility. Journal of General Internal Medicine. 1990;5(6):501-505.

7.       Horwitz L, Krumholz H, Green M, Huot S. Transfers of Patient Care Between House Staff on Internal Medicine Wards. Archives of Internal Medicine. 2006;166(11):1173.

8.       Volpp K, Grande D. Residents’ Suggestions for Reducing Errors in Teaching Hospitals. New England Journal of Medicine [Internet]. 2003;348(9):851-855. Available from: https://pubmed.ncbi.nlm.nih.gov/12606742/

9.       Kitch B, Cooper J, Zapol W, Hutter M, Marder J, Karson A et al. Handoffs Causing Patient Harm: A Survey of Medical and Surgical House Staff. The Joint Commission Journal on Quality and Patient Safety. 2008;34(10):563-570d.

10.     R. Vidyarthi A. Triple Handoff [Internet]. PS Net. 2006 [cited 27 April 2022]. Available from: https://psnet.ahrq.gov/web-mm/triple-handoff

11.     Riesenberg L, Leisch J, Cunningham J. Nursing Handoffs: A Systematic Review of the Literature. AJN, American Journal of Nursing [Internet]. 2010;110(4):24-34. Available from: https://pubmed.ncbi.nlm.nih.gov/20335686/

12.     Saleem A, Paulus J, Vassiliou M, Parsons S. Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: a cross-sectional survey. Canadian Journal of Surgery [Internet]. 2015;58(4):269-277. Available from: https://pubmed.ncbi.nlm.nih.gov/20335686/

13.     Global Patient Safety Action Plan 2021-2030 [Internet]. World Health Organization; 2021 [cited 27 April 2022]. Available from: https://www.who.int/publications/i/item/9789240032705

14.     Safe handover: safe patients [Internet]. 1st ed. Royal College of Physicians; 2018 [cited 27 April 2022]. Available from: https://www.rcpch.ac.uk/sites/default/files/2018-02/bma_handover_college_tutors.pdf

15.     The Joint Commission. Sentinel Event Alert [Internet]. Department of Corporate Communications; 2017. Available from: https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_58_hand_off_comms_9_6_17_final_(1).pdf?db=web&hash=5642D63C1A5017BD214701514DA00139&hash=5642D63C1A5017BD214701514DA00139