Continuity is vital in patient handover

According to the Royal College of Physicians ‘Clinicians Guide to Record Standards’ the handover of patient care from one professional or team to another is one of the highest risk transactions undertaken by healthcare services. Furthermore, guidance issued by the Royal College of Surgeons states that effective handovers between shifts should aim to convey high-quality and appropriate clinical information to oncoming healthcare professionals to provide for the safe transfer of responsibility for patients. Good handovers, therefore, are essential in providing continuity of safe patient care, the transfer of professional accountability and for error avoidance, thereby aiming to ensure that after handover all members of the healthcare team should have the same understanding and the same set of priorities. However, since the introduction of the European Working Time Directive (EWTD) in August 2009, virtually all staff in NHS organisations should now be working no more than 48 hours a week. The purpose of the EWTD is essentially to ensure both the safety of patients and the safety of NHS staff by improving the quality of training and the work/life balance of junior doctors and other healthcare staff. As a result this has posed a major challenge for acute specialties such as obstetrics, paediatrics, surgery and anaesthesia, which have all faced particular difficulties due to the need to have specialty clinical services available 24 hours a day. Consequently, the importance of robust systems of clinical handover has become of even greater significance to ensure patient safety in these and other acute clinical and surgical specialities.

Handover challenges

Effective clinical handover of patients poses a variety of challenges to NHS organisations. Passing information involving care delivered by a number of clinicians in handovers to or from a Trusts “Hospital at Night” team, for example, can be complex and demanding. Information must be selected for significance and priority. However, handovers are often multi-professional in nature and this means that different professionals will have different information requirements, further increasing the complexity of the process. In addition, admission processes can be complex and patients may also need to be transferred to other sites during the shift, creating additional logistical difficulties for staff. Unfortunately however, if clinical handover is not conducted correctly the consequences for patients can be potentially serious, as an October 2009 Sunday Times article A Series of Avoidable Deaths highlighted. This anonymised report outlined how in one case, information about a patient’s obstruction had not been passed from one junior doctor to the next when they changed shifts, with serious consequences ensuing. In another case, information about a patient’s medical condition had become confused in handovers between specialist registrars, while another patient underwent unnecessary surgery as instructions were not passed on to the next shift. In one extreme incident, an emergency operation for a hernia was not handed to the next shift and the patient became “lost” in the hospital system for three days. Comments made by John Black, president of the Royal College of Surgeons, should not, therefore, come as a surprise. He said: “Multiple handovers are inherently unsafe and are accidents waiting to happen.”