Duties and responsibilities
Improving patient handovers
Originally published March 2016
To be effective, a patient handover requires an exchange of information that is correct, meaningful, and adequate, and includes opportunities to discuss the information and ask questions for clarification.1 A number of barriers can hinder handovers and heighten risks for both patients and physicians.2 To manage the risks, physicians will want to consider various strategies to overcome these barriers.
A patient handover is the transfer of responsibility and accountability for some or all aspects of care for a patient or group of patients, temporarily or permanently.1
What the CMPA’s cases show
In an analysis of its medical-legal cases (2010 – 2014) involving handovers, the CMPA identified the following as contributing to problems with handovers, a number of which involve communications:
- Setting (i.e., busy work environments with frequent interruptions and distractions)
- Time constraints
- Incompatible communication styles
- Missing information about the patient’s condition or care plan including its documentation
- Lack of the use of a standardized communication tool
- Lack of training on safe patient handovers
Overcoming barriers, improving handovers
Patient safety experts and researchers offer various strategies for physicians to achieve more effective handovers. A few are briefly described here.
To address communication barriers, some experts advocate that, whenever possible during a handover, information is shared face-to-face instead of via electronic or written vehicles such as text messages or whiteboards.3 Some recommend that providers sit side-by-side, looking at the sign-out tool or patient list or computer screen together.4 This position may also allow for interactive questioning. To help ensure they’ve understood the information being conveyed, providers assuming care of a patient are encouraged to actively listen during the handover and to read back or repeat the information they’ve heard.5
Standardized or structured communication approaches to sharing information are often promoted by patient safety experts. There are many structured communication tools (mnemonic techniques) available to help recall important handover steps from memory, for example SBAR (which stands for Situation, Background, Assessment, and Recommendation) and IPASS6, 7 (which stands for illness severity, patient summary, action items, situation awareness and contingency planning, and synthesis by receiver).
Structured communication tools typically include the following components1:
- the patient’s history including background information and the current situation
- the assessment, what might happen next, and what the patient and family have been told
- a recommended plan with a pending list of action items and contingency plans should a particular scenario occur
- interactive questioning where providers accepting a handover can verify their understanding of the situation, assess the reasonableness of any recommended plans, and read back critical information
A more detailed description of such tools is available on the CMPA Good Practices Guide website. (The CMPA does not endorse any specific structured communication approach or tool.)
Researchers in one study of handovers found that choosing a quiet place to limit the number of interruptions and distractions contributed to improving the process.3
To overcome time constraints, experts suggest setting aside a specific time for transferring information8 and prioritizing the information to be discussed such as starting with the sickest patient.9 Some studies have found that using a standardized or structured communication tool can increase the content of information transferred without increasing the time to perform the handover.10 Others suggest using technology that automatically downloads important patient information into a template to shorten the time spent on team rounds.11
Training geared specifically to handovers can also result in improvements. For instance, experts have found that teaching providers how to use clear, unambiguous language during handovers can prevent information from being misinterpreted.8
Some experts encourage healthcare providers to involve the patient (and with the patient’s permission, the family) directly in a handover. This makes the patient aware that there is a change to a new team or most responsible physician, allows the history to be clarified and any misinformation corrected, and provides an opportunity to address any questions and concerns.1
Because important information can be lost during handovers, it may be prudent for physicians who are assuming care of a patient to go over the clinical history directly with the patient, and then enter the key handover information into a paper or electronic log.1 (Watch a CMPA video, "Documentation — A lawyer's story" to learn more about good documentation during a handover.)
These are just a few of the possible strategies to improve patient handovers. Many others are discussed in the literature. When investigating how to make handovers more effective, physicians are encouraged to consider their own particular needs and setting before deciding what approaches would work for them.
- CMPA Good Practices Guide [Internet]. Ottawa: The Canadian Medical Protective Association. Handovers; 2012 [cited 2015 Dec 16]; [about 5 screens]. Available from: https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/Handovers/what_is_a_handover-e.html
- CMPA Risk Fact Sheet: Patient handovers. Ottawa: The Canadian Medical Protective Association; 2013 [cited 2015 Dec 16]. 2 p. Available from: https://www.cmpa-acpm.ca/en/cmpa-risk-fact-sheets
- Solet D, Norvell M, Rutan G, Frankel M. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med [Internet]. 2005 Dec [cited 2016 Jan 27]80(12);1094-1099. Available from: http://med.stanford.edu/shs/update/archives/DEC2009/Lost_in_Translation.pdf
- Frankel R, Flanagan M, Ebright P, Bergman A, O’Brien C, Franks Z, Allen A, Harris A, Saleem J. Context, culture and (non-verbal) communication affect handover quality. BMJ Qual Saf [Internet]. 2012 [cited 2016 Jan 27];21:i121-i127. Available from: http://qualitysafety.bmj.com/content/21/Suppl_1/i121.full doi: 10.1136/bmjqs-2012-001482
- Barenfanger J, Sautter RL, Lang DL, Collins SM, Hacek DM, Peterson LR. Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol [Internet]. 2004 Jun [cited 2016 Jan 7];121 (6): 801-803. Available from: http://ajcp.oxfordjournals.org/content/ajcpath/121/6/801.full.pdf doi: 10.1309/9DYM6R0TM830U95Q
- Starmer A, Spector N, Srivastava R, Allen A, Landrigan C, Sectish T and the I-PASS Study Group. I-PASS, a Mnemonic to standardize verbal handoffs. Pediatrics [Internet]. 2012 Jan 9 [cited March 16, 2016]:129 (2);201-204. Available from: http://pediatrics.aappublications.org/content/129/2/201 doi: 10.1542/peds.2011-2966
- Starmer A, Spector N, Srivastava R, West D, Rosenbluth G, Allen A, Noble B, Tse L, Dalal A, Keohane C, Lipsitz S, Rothschild J, Wien M, Yoon C, Zigmont C, WilsonK, O’Toole J, Solan R, Aylor M, Bismilla Z, Coffey M, Mahant S, Blankenburg R, Destino L, Everhart J, Patel S, Bale J, Spackman J, Stevenson A, Calaman S, Cole S, Balmer D, Hepps J, Lopreiato J, Yu C, Sectish T, Landrigan C, for the I-PASS Study Group. Changes in medical errors after implementation of a handoff program. New Engl J Med [Internet]. 2014 Nov 6 [cited 2016 March 16];371:1803-1812. Available from: http://www.nejm.org/doi/full/10.1056/NEJMsa1405556 doi: 10.1056/NEJMsa1405556
- WHO Collaborating Centre for Patient Safety Solutions. Communication during patient hand-overs. Patient Safety Solutions [Internet]. 2007 May[cited 2016 Jan 27];1(3). Available from: http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf
- Cohen M, IIan R, Garrett L, LeBaron C, Christianson M. The earlier the longer: disproportionate time allocated to patients discussed early in attending physician handoff sessions. Arch Intern Med [Internet]. 2012 Dec [cited 2016 Jan 27];172(22):1762-1764. Available from: http://archinte.jamanetwork.com/article.aspx?articleid=1391009 doi: 10.1001/2013.jamainternmed.65.
- Thompson J, Collett L, Langbart M, Purcell N, Boyd S, Yuminaga Y, Ossolinski G Susanto C, McCormack A. Using the ISBAR handover tool in junior medical officer handover: a study in an Australian tertiary hospital. Postgrad Med J. 2011; 87:340-4.
- Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg, 2005; 200(4);538-545.