Safer handovers for patients

The Royal College of Physicians (RCP) has recently launched the first in a series of toolkits aimed at offering guidance on best quality care. The toolkit identifies poor handover between doctors, nurses and multidisciplinary teams as a common cause of error in hospitals and is a major preventable cause of patient harm. Poor handover, it says, can lead to inefficiencies, incorrect treatment, delayed decisions, repeated investigations, incorrect diagnoses, incorrect treatment and poor communication with the patient.1 Additional reasons for the development of the toolkit are identified by the RCP as increasing pressure within the hospital service, particularly related to the European Working Time Directive (EWTD) which has shortened the medical trainees working day, increasing the need and likelihood of handovers between trainees and teams occurring. Dr Cordelia Coltart, RCP clinical adviser, who helped develop the toolkit, said: “The current moves towards shorter working hours must not detract from the ultimate responsibility of doctors to ensure safe, efficient and effective care for their patients. Handover has been identified as a particularly ‘high-risk’ step in the patient pathway, where errors are likely to occur. These errors are preventable and this toolkit aims to give practical guidance to assess and improve the handover process within your Trust to improve patient safety and care.”

Handovers

Handovers have been identified in patient safety literature as being a point at which errors are likely to occur. Failure in handover is a major preventable cause of poor communication and systemic error. In April 2010, the RCP undertook a survey and came up with some surprising data. Handovers with transfers in responsibility are a frequent occurrence – handover is most commonly passed between consultants and their junior teams once or twice within every 24 hours (69% and 66% respectively) but 27% of respondents identified situations where care is passed between teams of juniors three times or more within 24 hours. When acute or “covering” consultant changes, active consultant participation in handover is uncommon (acute take handover: 34%, service handover: 32%, hospital-wide handover: 9%). Handover may only occur between trainees, so the consultant may not be explicitly aware of their responsibilities. The RCP survey found that 91% of those surveyed knew what constituted a “good” handover; 50% said that when handover occurs as part of the general medical take, it is only verbal (i.e. no documentation is produced); 38% reported instruction on handover process during Trust induction; 18% reported education on handover within in their Trust; 34% reported that no handover time was scheduled into working patterns; 33% agreed that handover was currently done well; 72% identified that handover was an important issue; and 80% felt that there was a need to understand how to implement handover. The new RCP toolkit includes templates which demonstrate and record the handover – implicitly incorporating and embedding a standardised procedure for handover – and it is a move that should be welcomed. A standardised clinical handover should include the following: