Every year, the MDU receives calls about problems arising from the handover process.
While many of these are connected to confidentiality breaches – for example when a doctor's handover sheet is lost, only to be discovered by a member of the public – we see many more where a patient has suffered an adverse outcome due to poor transfer of information.
Like any incident resulting in patient harm or even death, doctors involved can face multiple jeopardy. In other words, although the case stems from an error or oversight made during handover, the resultant investigations vary from complaints, adverse incidents and claims to coroner's inquests.
The following three cases, based on our files, demonstrate some of the problems that can arise from handover.
A junior doctor contacted the MDU for assistance with writing an adverse incident statement after a post-operative patient was admitted to ITU. It transpired that the patient had been omitted from the handover and therefore had not been reviewed by one of the surgical team for an entire weekend, during which time they became acutely unwell.
A medical registrar requested assistance with a coroner's case after she had not realised that she was meant to repeat blood tests on an acutely unwell patient and review him during a night shift. She had understood that another member of the team would be doing this. It was only when the patient arrested that the member saw him for the first time.
An obstetric registrar approached the MDU for advice about raising concerns. He had asked his colleague to check a patient's blood results, only to discover the next morning that she had not done so.
Fortunately, the patient had not come to any harm but when the registrar asked his colleague about this omission, she claimed that he had not handed this task over to her.
There had been several similar incidents previously when this doctor had not acted on information she had been given during handover, which caused the member to have patient safety concerns.
How can such incidents be avoided?
Handovers are vital in providing continuity of care, which in turn helps to secure patient safety. In an ideal world, handovers should entail all of the relevant information about patients being relayed to those members of staff taking over their care, and this should be done with adequate time and a lack of interruptions.
The GMC gives clear advice on its expectations regarding handovers in the publication Good medical practice (2013):
44. You must contribute to the safe transfer of patients between healthcare providers and between health and social care providers. This means you must:
a. share all relevant information with colleagues involved in your patients' care within and outside the team, including when you hand over care as you go off duty, and when you delegate care or refer patients to other health or social care providers.
The term 'all relevant' information will have different meanings in each case, and it can be difficult to strike a balance between being comprehensive enough to allow the receiving team to provide safe care, and overloading them with excessive information.
The challenge of handing over details about large numbers of patients with complex needs can be further complicated by the circumstances in which this handover occurs. The Royal College of Physicians' acute care toolkit outlines that adequate time should be designated for handovers and leadership roles and responsibilities should be clearly defined.
It also recommends that hospitals adopt standardised methods which are specially tailored for different units or needs – such as A&E, general ward, and so on.
When considering what information to relay, it may be helpful to bear the following in mind:
- Be on time and be organised.
- Prioritise important information so that key points don't get lost in 'white noise'. It's not unreasonable to spend more time discussing those patients that are very ill or who have the potential to become so.
- Flag up situations that may lead to errors, such as where patients are outliers, those who have similar names or if there have been problems in providing care to a patient so far during their stay.
- Expectations need to be made clear, such as who will be responsible for what, what tasks are still pending and which of these are the most pressing. If you are not clear on where the responsibility lies or of the plan for a certain patient, ask.
- Similarly, if you are asked for details that you cannot answer, say so. Don't bluff or guess the answer, as this could impact how others plan their priorities during the shift.