Reducing risk arising from patient handovers

Ms Niamh Gallagher advises on how to improve communication in relation to patient handovers

Communication breakdowns in healthcare settings are not uncommon, and they can result in anything from minor confusion to serious patient harm. In an analysis of more than 19,000 claims over the period 2010-to-2019, our underwriter MedPro found that sub-optimal communication was second only to clinical judgement as the largest contributing factor in claims. Delving deeper into the types of communication issues, MedPro’s analysis revealed that in 70 per cent of cases involving sub-optimal communication as a contributing factor, the communication in question was taking place between clinicians and with other healthcare providers. 

Successful communication in a healthcare setting has always been a core element of patient safety, and with the shifting focus toward collaborative and team-based care, coupled with pressures from unprecedented waiting lists and staff shortages, the need for consistent, accurate, and effective communication between healthcare providers is becoming even more challenging.

Patient handover

The Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (the ‘Guide’) defines handover as the “transfer of professional responsibility and accountability for some or all aspects of the care of a patient or group of patients, to another person or professional group on a temporary or permanent basis”.

The Guide recognises that handovers take place between teams and/or between individuals and provides the following advice:

“When you hand over care for a patient to another healthcare professional, team, and/or institution, you should check that they understand and accept responsibility for the patient’s care. You should pass on all relevant information about the patient and the patient’s care. When discharging patients back to primary care, you should give all relevant information promptly.”

Clinical teams rely on good communication to function effectively and efficiently and, most of all, to provide safe and reliable patient care. Clinical handovers between colleagues facilitate shared situational awareness of a patient’s condition and are an essential component of the care process. Incomplete or inadequate handover is commonly associated with adverse clinical incidents, poor patient outcomes, and prolonged hospital stays.  

When do patient handovers occur?

Patient handovers typically occur when there is a:

• Transfer of patients from primary to secondary care and back at time of discharge;

• Transfer of patients between departments/wards/teams in a hospital;

• Transfer of patient care during a shift change for staff or between on-call providers.

The information set that should be shared during each of the types of patient handover listed above varies, as does the method, or means of communication of that information. Below are some of the issues that should be considered to ensure a safe and effective patient handover in each case.

1. Patient handovers from primary to secondary care and back

In 2011, HIQA published a report and recommendations on patient referrals from general practice including guidance on standardised referral forms from GPs to secondary care. HIQA also devised national standards for patient discharge summaries, which were published in 2013.

Standardised referral letters and discharge letters can reduce the risk of miscommunication as doctors in both primary and secondary care will know what to expect and, more importantly, be alerted to any information missing. Standardised communication ensures that care can be delivered efficiently and without unnecessarily having to lose valuable time obtaining further patient information. 

All patient identifiable information should be transferred in a timely manner and using secure systems, such as Healthlink or Healthmail. At a minimum the following information should be provided between primary and secondary care:

At referral

• Indication for referral;

• Past medical history;

• Current clinical status;

• Current medications and allergies;

• Results of any relevant investigations;

• Family history if relevant.

At discharge

• Diagnosis and treatment;

• Known and pending tests results;

• Discharge medications, especially if changes have been made to a prior medication regime or if medication monitoring is required;

• Recommended follow-up and required monitoring;

• Engagement of other services, eg, public health nurse, physiotherapist, etc;

• Ensure that the discharge summary is promptly sent to the GP. Consider providing a copy of the discharge letter to the patient.

As with all stages of the patient care journey, it is important to highlight any outstanding investigations or results when handing over patient care. Clinicians should be aware that clinical governance for communication and follow-up of test results lies with the requesting clinician unless otherwise agreed. 

Of course, a patient referral or discharge summary can’t replace or reduce the need for the doctor to discuss diagnoses, treatment, and follow-up plans with the patient. At both referral and discharge, it is important to keep the patient fully informed about the nature of their illness, medications prescribed, and any follow-up investigations or appointments. Details of all such conversation should be recorded in the patient’s clinical record.

A study by Dinsdale E, Hannigan A et al, published in 2020, highlighted deficits in communication between primary and secondary care. Data examining 3,293 referral letters and 2,468 discharge letters across 68 GP practices and 17 hospitals across Ireland was compared with international guidelines. Findings concluded:

Referral letters

• 82 per cent included current medications;

• 65 per cent did not include information relating to patient management up to the point of referral;
• 57 per cent did not detail medication allergies.

Discharge letters

• 30 per cent omitted medication changes;

• 33 per cent omitted medication lists;

• 13 per cent omitted secondary diagnosis.

2. Patient handovers between departments/wards/teams

Handovers occur regularly in hospital settings where patients are transferred between wards and treating clinical teams.

The HSE has developed a clinical education programme and published very useful training videos on its website to mitigate risk during patient handover. 

The HSE’s best practice guidance recommends handing over the patient’s chart in person and going through it with the next treating clinician. It also recommends asking the next clinician  to confirm that they have all of the information they need to take over the care of the patient.  

The following information should be shared between staff at this juncture:

• Any changes in patient management strategy;

• Patient status before and after any significant medical intervention;

• Any previous transfers within the hospital, ie, to other wards/ICU;

• Communication with family members/next-of-kin;

• End-of-life decisions, if appropriate;

• Any red flag information should be communicated verbally, as well as being recorded in the notes.

There are a number of communication techniques that have been developed for the purpose of improving communication among multidisciplinary teams. One of the most relevant to patient handovers in a hospital setting in Ireland is ISBAR/ISBAR3, as it has been adopted by the HSE for training programmes on patient handovers. ISBAR3 is a well-recognised structured communication tool, originally developed by the US Navy; communication between nuclear submarines that has been recommended for use in healthcare settings by the World Health Organisation since 2007.

• Identify – identify yourself, who you are talking to, and to whom the information relates.

• Situation – identify the patient’s current condition, concerns, and observations.

• Background – establish the clinical background or context of the situation.

• Assessment – identify the potential condition or problem based on medical findings.

• Recommendation – initiate a specific, actionable response/plan.

• Read-back – ensure your communication has been delivered and understood by asking recipients to confirm.

• Risk – consider any risks and patient safety issues.

The above tool can be implemented and tailored to suit any patient handover scenario. As with any communication tool or protocol adopted by a hospital or in the healthcare sector generally, successful implantation requires that all healthcare providers are aware of the tool and have received appropriate training and retraining in its use.

3. Patient handovers at shift change

All clinicians will be familiar with the handover patients during shift changes. The HSE recommends use of the ISBAR3 model outlined above for these type of handovers. Shift changes are generally busy with lots of people coming and going. It is crucial that any change in condition, medication or treatment is communicated during the handover. Any upcoming surgeries or investigations should also be flagged at handover stage.

Conclusion

A number of large-scale studies on errors in the delivery of healthcare, including the above mentioned analysis by MedPro of its claims over the past 10 years, report that sub-optimal communication has consistently been a major contributing factor to poor patient outcomes. Although to err is human, some errors, such as communication errors among healthcare providers, are more avoidable than others. Medisec supports initiatives by the HSE, the ICGP, and HIQA to introduce national standards when it comes to GP referral letters, hospital discharge letters, and handovers within a hospital setting. 

Consistent adoption of in-hospital patient transfer tools, such as ISBAR, as well as regular training and audit for all healthcare providers, can go a long way towards minimising and preventing risks during a patient handover.

With increasing pressure on our hospital systems, it is vital, now more than ever, that all healthcare providers work together to eliminate avoidable errors, in the interest of delivering best in class healthcare.

References available on request