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Transferring care to others

Barriers to effective handovers

Young girl whispering into a boy's earBe aware of high-risk times in your workplace. Handovers at end-of-shift, end-of-day, end-of-week, and at the time of any planned or unplanned absence are all high-risk times for a patient to "slip through the cracks."

The broken telephone party game played by children illustrates how information is often lost or changed during verbal communications. The first player whispers information to another who repeats it to the next in line and so on. The last player announces the retold and usually distorted information to the group.

Case: Handover failure
X-ray image of cervical spine


Mark is a 22-year-old who has a neck injury sustained in a snowboarding accident. Although he is neurologically intact, Mark is diagnosed with a C6 fracture and a C6/C7 subluxation with 3.5 mm anterolisthesis.
Surgical team under lights

Operative course

The staff neurosurgeon performs a C6/C7 fusion, inserting pedicle screws to stabilize the spine.
Two male physicians in discussion

Operative course continued

He asks the resident to order a follow-up CT scan of the cervical spine on day 3 post-op.
Imaging machine


The CT scan is performed on day 3. The radiologist notes in her report that the pedicle screws are not positioned correctly and appear to be transecting the vertebral arteries. There is no direct communication of these findings to the neurosurgical team.

Press play for details.
Male physician on phone


The same day the neurosurgery resident transfers care of all his patients to the weekend on-call resident. He mentions that Mark has had a CT scan of his cervical spine and could probably be discharged the following day. The on-call resident assumes that his colleague has reviewed the CT scan. He discharges the patient the next day.

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Male patient in stretcher being pushed by three hospital staff

Clinical outcome

Two days later Mark is rushed back to hospital after developing right-sided hemiparesis, diplopia, and ataxia. An angiogram reveals that one of the screws had injured a vertebral artery, resulting in a stroke.
Empty wheelchair

Outcome continued

Mark is left paralyzed on the right side and can no longer walk independently.

Think about it

  • How could the handover between the residents have been done differently?
  • How might communication between the staff neurosurgeon, the radiologist, the residents and the patient have been better?

Lessons learned

  • Effective communication between healthcare providers is essential during handovers.
  • Providing insufficient information, lack of interactive questioning, and lack of time can contribute to ineffective handovers.
  • Roles and responsibilities should be clarified when handing over responsibility for a patient.

Barriers to effective handovers

There are many barriers to effective handovers in the workplace.
(Read as text only)
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Click on each box in the diagram for examples of barriers to effective handovers.

Failure to use standardized communication tools

Communication styles

The setting

Time constraints

Missing information

Lack of training

Failure to use standardized communication tools

A structured approach for handovers, including interactive questioning, helps to verify the information being transferred.