Handover harms? A survey of patient handover safety and an innovative tool for better practice

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Healthcare professionals are bound by an oath to do no harm to their patients. In 21st century medicine this goes beyond mere harm prevention to providing high quality care tailored to each patient’s unique needs. Unfortunately, more often than not, diligent individual effort in managing patient care is wasted in the complex process of patient handover; an area where poor communication results in unnecessary medical error, delay and harm.

Today, on World Patient Safety Day 2021, the CAREFUL team has undertaken to launch our own research into the sentiments of healthcare professionals on handover processes and the perceived risk when these are poorly conducted. We will also identify barriers to effective information transfer, as well as the current systems and tools being used to improve the process.

Handover is the transfer of professional responsibilities and accountability for a patient or group of patients’ care from one person or team to another for a temporary or permanent basis(1).  It is where one group disengages as another engages. 

Like the passing of a baton in a relay, where precious hundredths of a second can determine race outcomes, handover requires scrupulous attention to sequence, timing, technique, and communication – all within a very limited time window. However, while professional athletes devote endless resources and energy into perfecting this motion, shockingly little formal attention, education or evaluation has been conducted to reinforce this essential link in the continuity of patient care. 

We believe strongly that our research is keenly aligned with the overall objectives of World Patient Safety Day to enhance global understanding of patient safety, increase public engagement in the safety of healthcare and promote global actions to enhance patient safety and reduce patient harm. The origin of the Day is firmly grounded in the fundamental principle of medicine: First, do no harm.


The critical role of healthcare providers in ensuring patient safety during handover is increasingly recognised and emphasised by various governing bodies. Internationally, the World Health Organization (WHO) has included this as part of their 2021-2030 “transition of care” strategy. It is furthermore included in the General Medical Councils (GMC) publication, Good Medical Practise, that all doctors will “keep colleagues well informed when sharing the care of patients”(2).

The importance of employing a standardised handover approach is further underscored in many large educational institutes such as 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 standards(3).

While perceived to be critical, handover is often carried out in a haphazard fashion, with the method and extent of information transferred varying considerably from each clinician(4). Compounded by the frequency of handover in healthcare settings, with an estimated 4,000 handovers occurring each day in a typical teaching hospital(5), it is a procedure prone to a multitude of errors(6).

The problem with handover

Sub-optimal handover is costly for both patients and the healthcare professionals involved. It results in significant morbidity, mortality, dissatisfaction, and excess financial costs. The Joint Commission Sentinel Event statistics for 2015 identified that communication breakdown was the 3rd most frequent root cause of sentinel events (7). It also became the subject of Issue 58 of The Joint Commission’s Sentinel Event Alert in 2017 (8).

Furthermore, a 2016 study by CRICO Strategies estimated that communication failures in American hospitals and medical practises accounted for at least 30% of malpractice claims, resulting in 1,744 deaths and over $7 billion worth of financial loss over 5 years.(9) Delays resulting in unnecessary prolongation of hospital stays have also been reported(10, 11), putting excessive strain on healthcare systems already struggling with the increased pressures of new patients and the backlog of delayed procedures as a result of the COVID-19 pandemic.

Barriers to effective handover

Handover is one of the most vulnerable, recurring processes in healthcare. Appropriate and timely handover requires precise and complete information transfer, filtering unnecessary details while maintaining essential medical information and action points. It is affected by a complex combination of social and non-verbal cues, as well as various cultural and organisational factors, in addition to individual competency.

Studies on barriers to effective handover have observed that social status differences, hierarchical differences and concern over interpersonal power and conflict are a cause for communication failure(12). Language differences have also caused confusion, insofar as while clinicians may speak a common ‘medical language’, much information can be lost or misconstrued in the transfer between clinicians of different ethnic and geographic backgrounds(13). 

Physical barriers include lack of appropriate location or time, excessive noise and interruptions, in addition to structural challenges such as lack of appropriate training, work overload and insufficient manpower(6, 14, 15).  

New age tools

Several tools, checklists and protocols for improving communication during handover have been widely advocated and studied in various settings and departments – though many lack rigorous evaluation and significant positive outcomes.

Mnemonics are an easy-to-remember communication mode used by clinicians to succinctly summarise and transfer relevant information during handover. Situation, Background, Assessment, and Recommendation (SBAR) is the most mature and widely used(16). Others include iSoBAR(17), SHARE, and PSYCH(18). While there is some evidence for the effectiveness of such mnemonics on patient outcomes, a systematic review of 14 mnemonics revealed that only half of the studies found significant improvement on patient outcomes, and evidence was also limited to specific circumstances or settings(6). Although some small scale trials have shown benefits of the implementation of such mnemonics, high quality research is indeed still lacking(19).

Electronic and computerised tools are also being developed to help cut communication errors that occur during patient handovers. The I-PASS Patient Safety Institute tool utilises cloud-base benchmarking software to allow easy access by providers on various digital platforms. Its use has resulted in a 30% reduction in preventable adverse events and 23% relative reduction in the rate of all medical errors, saving the hospitals between $10 million to $20 million in three years(20). While it is certainly the most widely used thus far, several other tools, such as TeamSTEPPS and the Joint Commission Centre for Transforming Healthcare’s Targeted Solutions Tool (®)(TST(®)) have been implemented and trialled in various hospitals internationally and shown significant advancement in quality of handover(21-23) 

The CAREFUL platform, a revolutionary communication tool that we have developed in response to the risks associated with handover, enables collaboration within and between teams through shared visibility of tasks and unambiguous accountability for actions.

CAREFUL replaces inadequate, informal and manual systems with a single platform. All relevant tasks in a patient’s care can be planned, tracked, recorded, shared and handed over between individuals, teams and organisations. Patient safety is improved because nothing is lost or forgotten.

Current evaluative tools

There is evidently a multitude of idiosyncratic handover systems within hospitals, units and services. This does not, however, solve the issue of handover inconsistency between different healthcare sites and settings. There is also paucity of high quality data evaluating the effectiveness of such tools, and to delineate best practise[1]. This may be accounted for by the difficulty in obtaining data for safety and quality interventions that are essentially changes in complex social practises. Yet, it is the type of evidence that may best be used to motivate healthcare professionals to make changes in their handover process.

Modern hospitals and healthcare systems are becoming increasingly specialised, patient treatment is becoming more complex and there is a burgeoning population of patients with increasing healthcare needs. The difficulty and frequency of handover has therefore increased, making it likely that many – if not most – of the severe risks to patient safety can be found in patient handover. Although research is inconclusive about interventions to improve handover, there is clearly a need to review and rethink a process that has perhaps become too comfortably routine.

Our research

Today, we have deployed a quantitative opinion survey through social media channels, and personal networks to capture the opinions of multidisciplinary clinicians, their managers and leaders in a variety of settings internationally. The survey seeks opinions on the risk and safety of transitions of care in the experience of the respondents. This will include peer-to-peer handover and internal referrals as well as discharges and transfers between organisations.

Error and patient harm are shamefully common in healthcare. This is not the fault of the practitioners who struggle every day to keep patients safe. It is the inadequacy, poverty and poor design of the systems which surround them. Through our research into the risks associated with handover, barriers to effective transfer and the tools currently being used to improve the process, we intend to address what we understand to be one of the principal poorly controlled risks in healthcare.

If you would like to take part in our anonymous Handover Safety Survey, you can do so here. Your answers will help improve the care of patients and service users and support the CAREFUL team in our efforts to underscore the need for changes to clinical practise.

  1. Australian Medical Association. Safe handover: safe patients. AMA Clinical Handover Guide. AMA, Sydney, 2007. Available from: https://www.ama.com.au/sites/default/files/documents/Clinical_Handover_0.pdf
  2. General Medical Council. Domain 3: Communication partnership and teamwork [Available from: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-3—communication-partnership-and-teamwork.
  3. Sentinel Event Alert. The Joint Commission; 2017.
  4. Volpp KG, Grande D. Residents’ suggestions for reducing errors in teaching hospitals. N Engl J Med. 2003 Feb 27;348(9):851-5. doi: 10.1056/NEJMsb021667. PMID: 12606742.
  5. Vidyarthi AR. Triple handoff. AHRQ Web M&M, September 2006.
  6. Riesenberg LA, Leitzsch J, Cunningham JM. Nursing handoffs: a systematic review of the literature. Am J Nurs. 2010 Apr;110(4):24-34; quiz 35-6. doi: 10.1097/01.NAJ.0000370154.79857.09. PMID: 20335686.
  7. Joint Commission Perspectives: Sentinel Event Statistics released for 2015. Available from: http://info.jcrinc.com/rs/494-MTZ-066/images/Sentinel39.pdf.
  8. Sentinel Event Alert: Inadequate hand-off communication. Issue 58. 2017.
  9. CRICO Strategies. Malpractice risk in communication failures; 2015 Annual Benchmarking Report. Boston, Massachusetts: The Risk Management Foundation of the Harvard Medical Institutions, Inc., 2015
  10. Lofgren RP, Gottlieb D, Williams RA, Rich EC. Post-call transfer of resident responsibility: its effect on patient care. J Gen Intern Med. 1990 Nov-Dec;5(6):501-5.
  11. Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006 Jun 12;166(11):1173-7.
  12. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004 Feb;79(2):186-94.
  13. Weech-Maldonado R, Morales LS, Elliott M, Spritzer K, Marshall G, Hays RD. Race/ethnicity, language, and patients’ assessments of care in Medicaid managed care. Health Serv Res. 2003 Jun;38(3):789-808.
  14. Holly C, Poletick EB. A systematic review on the transfer of information during nurse transitions in care. J Clin Nurs. 2014 Sep;23(17-18):2387-95.
  15. Ong MS, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf. 2011 Jun;37(6):274-84.
  16. De Meester K, Verspuy M, Monsieurs KG, Van Bogaert P. SBAR improves nurse-physician communication and reduces unexpected death: a pre and post intervention study. Resuscitation. 2013 Sep;84(9):1192-6.
  17. Street M, Phillips NM, Haesler E, Kent B. Refining nursing assessment and management with a new postanaesthetic care discharge tool to minimize surgical patient risk. J Adv Nurs. 2018 Nov;74(11):2566-2576..
  18. Mariano MT, Brooks V, DiGiacomo M. PSYCH: A Mnemonic to Help Psychiatric Residents Decrease Patient Handoff Communication Errors. Jt Comm J Qual Patient Saf. 2016 Jul;42(7):316-20
  19. Riesenberg LA, Leitzsch J, Little BW. Systematic review of handoff mnemonics literature. Am J Med Qual. 2009 May-Jun;24(3):196-204.
  20. Shahian D. I-PASS handover system: a decade of evidence demands action. BMJ Qual Saf. 2021 Apr 23:bmjqs-2021-013314. 33893212.
  21. Nabors C, Khera S, Forman L, Kolte D, Mittal V, Marballi A, Agrawal S, Pawar R, OʼConnell D, Afanador SM, Kolandaivel K, Chugh S, Peterson SJ. Electronic Capture of Written Handoff Information: What Are the Next Steps? Am J Ther. 2016 May-Jun;23(3):e785-91
  22. BV S, SJ C. A shared electronic health record: lessons from the coalface. The Medical journal of Australia. 2009;190(S11).
  23. Desmedt M, Ulenaers D, Grosemans J, Hellings J, Bergs J. Clinical handover and handoff in healthcare: a systematic review of systematic reviews. Int J Qual Health Care. 2021 Feb 20;33(1):mzaa170.

[1] https://academic.oup.com/intqhc/article/33/1/mzaa170/6039082

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