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Handovers


Transferring care to others

Safer handovers through structured communications


Many patient safety experts recommend using structured communication approaches for sharing information during handovers. Many types of approaches — mnemonic techniques — are available to help increase memory recall of important steps. Several of these are being studied to establish their effectiveness. A healthcare organization may recommend a particular approach or tool.

While the use of structured communication tools holds promise, the rote use of such tools without the mental focus of all involved should be avoided. Appropriate discussion about the meaning of the information and opportunities to seek clarification and ask questions are important. Remember also that everyone may not be familiar with all of the terms and abbreviations used in a specialty, and these may require explanation during handover.

Sometimes the clinical situation is unclear or evolving, and a handover may be an opportunity for those assuming care to provide a fresh perspective on the patient's diagnosis, investigations or treatment.

The CMPA does not endorse any specific structured communication approach or tool. The following descriptions are offered only as examples of mnemonic techniques that many patient safety experts consider to hold promise in improving communication.

Examples of structured communication tools (mnemonic techniques) for handovers include the following:

SBAR

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SBAR

Situation

  • problem, patient's symptoms
  • patient stability or level of concern

Background

  • history of presentation
  • background information

Assessment

  • assessment and differential diagnosis
  • where you think things are headed

Recommendation

  • recommendations and action plan
  • what you have done
  • what you would like the other person to do

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Roll over letters for explanatory text
S
B
A
R

Situation

  • problem, patient's symptoms
  • patient stability or level of concern

Background

  • history of presentation
  • background information

Assessment

  • assessment and differential diagnosis
  • where you think things are headed

Recommendation

  • recommendations and action plan
  • what you have done
  • what you would like the other person to do
Case: Using SBAR
Side view of male and female physicians in discussion

John, a fourth-year medical student, is handing over his patient to Mary, the on-call resident in obstetrics and gynaecology. He decides to use SBAR as a structured communication tool.
S
B
A
R

Situation
"Mrs. White in room 231 is stable and has been admitted with a possible ectopic pregnancy."
S
B
A
R

Background
"She is a 28-year-old gravida 1 who is 8 weeks pregnant. She presented at 2 p.m. with a 2-day history of vaginal spotting and left-sided abdominal pain. She has gone through 2 pads today. Her vital signs are normal, and her abdomen is soft with mild tenderness in the left lower quadrant. On pelvic exam, the os is closed, and the patient has mild left adnexal tenderness with no mass. Her haemoglobin is 120 and her bHCG is 2032. She is Rh-positive."
S
B
A
R

Assessment
"She may have an ectopic pregnancy or a threatened abortion."
S
B
A
R

Recommendation
"She will be having an ultrasound in 1 hour. You need to review the results with the radiologist and then call Dr. Green. If the patient's pain increases or her BP drops below 100 you need to assess her and call Dr. Green right away. You also need to be careful. Her sister is here but she doesn't want her sister to know that she is pregnant."

Resident: "Got it. I will review the ultrasound in 1 hour and call Dr. Green, unless the patient becomes unstable while waiting. She doesn't want her sister to know she is pregnant."

Lessons learned

The use of this or other structured communication tools can help to organize and simplify intra- and inter-professional discussion about patient care, and has the potential to improve the clarity of communications and patient safety.

Note also the effective use of readback — the receiving person repeats back important information during a handover, which can improve everyone's understanding.

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I-PASS

[REF]
Starmer A et al. I-PASS, a mnemonic to standardize verbal handoffs. Pediatrics 2012; 192(2): 201-204.
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I-PASS

Illness severity

  • stable, "watcher", unstable

Patient summary

  • events leading to admission
  • hospital course
  • current condition
  • treatment plan

Action list

  • to-do list
  • timeline and who is responsible

Situation awareness and contingency planning

  • what's going on
  • plan for what might happen

Synthesis by receiver

  • closing the loop — readback
  • further questions

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Learn more about the I-PASS Study.

Roll over letters for explanatory text
I
P
A
S
S

Illness severity

  • stable, "watcher", unstable

Patient summary

  • events leading to admission
  • hospital course
  • current condition
  • treatment plan

Action list

  • to-do list
  • timeline and who is responsible

Situation awareness and contingency planning

  • what's going on
  • plan for what might happen

Synthesis by receiver

  • closing the loop — readback
  • further questions

SIGNOUT

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SIGNOUT

Sick or DNR

  • highlight the sick or unstable patients
  • identify code status

Identifying data

  • name
  • age
  • gender
  • diagnosis

General hospital course

New events of the day

Overall health status/clinical condition

Upcoming possibilities and plan

Tasks to complete

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Roll over letters for explanatory text
S
I
G
N
O
U
T

Sick or DNR

  • highlight the sick or unstable patients
  • identify code status

Identifying data

  • name, age, gender
  • diagnosis

General hospital course

Overall health status/clinical condition

Upcoming possibilities and plan

Tasks to complete

DRAW

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DRAW

Diagnosis

Recent changes

Anticipated changes

What to watch for in the next interval of care

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Roll over letters for explanatory text
D
R
A
W

Diagnosis

Recent changes

Anticipated changes

What to watch for in the next interval of care

Case: Failure to perform readback
Male and female physicians talking over electronic medical chart

Background

John is a first-year pediatric resident who receives a handover from his colleague Jenna. She tells him about a young child who has had several seizures treated with benzodiazepine. She advises him that if the child has another seizure, he is to administer intravenous phenytoin at 15 mg/kg at a rate of 1 mg/kg/minute.
Young girl smiling

Clinical outcome

John believes she has told him the dose is 50 mg/kg and orders this when the child has another seizure. The child becomes phenytoin toxic after receiving more than 3 times the usual dose.
Close up of intravenous bag

Lessons learned

Readbacks can be helpful in preventing misunderstanding of information during handovers. A readback may be especially useful for confirming:  
  • to-do (action) items
  • medication orders and dosing
  • critical lab results
  • equipment settings
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Involving patients and family

During illness the patient and family can play a helpful role in ensuring continuity of care.  

Some healthcare providers involve the patient (and with the patient's permission, the family) directly in the handover process. This approach:

  • informs the patient there is a change to a new team or most responsible physician
  • allows for clarification of the history and correction of any misinformation
  • provides an opportunity to address any questions and concerns

Case: Involving the family
Close up of woman at bedside of male patient with head wound

Background

Mr. Greg undergoes the evacuation of a subdural hematoma. The family is present during the handover when the team mentions that Mr. Greg would need a repeat CT scan the next day.

Unfortunately the requisition is misplaced and does not reach the diagnostic imaging department.

Two days later, the family realizes that the CT scan had not been performed, and brings this to the team's attention. This prevents a further delay in the test being performed.

Lessons learned

Keeping the patient or family informed of the planned investigations, treatment and follow-up plans is important for good communication and may add an extra safety measure to limit the likelihood of some aspect of care being overlooked.
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Case: A 38-year-old man with gastrointestinal bleeding
Blurred image of male patient in stretcher being pushed by three hospital staff

Background

A patient with a significant upper gastrointestinal bleed was admitted to a community hospital under the care of Dr. A.

A peptic ulcer was suspected.

The patient's condition worsened and Dr. A transferred him to the tertiary care hospital, where Dr. B performed a gastroscopy. Dr B made a preliminary diagnosis of a Dieulafoy-type lesion a rare condition involving bleeding from a larger than usual artery in the gastric submucosa. The exact origin of the bleeding is often difficult to locate and treat.

Background continued

Dr. B was off call for the weekend, and the care of the patient was transferred to Dr. C, a senior surgeon on-call. However, Dr. B did not inform Dr. C of the diagnosis or the treatment plan. Dr B knew the patient needed to be monitored closely and at the first sign of re-bleeding an immediate endoscopy needed to be performed to locate and repair the Dieulafoy's lesion. There was no note of this written in the medical record.

Over the weekend, the patient again began vomiting blood, and his condition suddenly deteriorated. Unfortunately the patient suffered a cardiac arrest while being re-investigated and could not be resuscitated.

The family commenced a legal action against many physicians, including the Doctors A, B, and C.

Legal outcomes

  • Dr. C (on-call surgeon) was dismissed from the action prior to trial.
  • At the trial, the action against Dr. A was dismissed; however, the court found against Dr. B (receiving surgeon at the tertiary centre).
  • The family was awarded compensation, paid by the CMPA on behalf of Dr. B.

In his decision the judge noted, given the diagnosis, the high risk to the patient and the nature of the treatment plan, careful monitoring of the patient and appropriate intervention was likely to be required. It was therefore incumbent on Dr. B to take all reasonable steps necessary to ensure the patient's history was communicated to Dr. C and the treatment plan was followed.

Close up of male hand holding gavel

Legal outcomes continued

If Dr. B had carefully explained to Dr. C in detail the history and precarious nature of the patient's condition and the significant danger attendant upon re-bleed, it would be highly unlikely that Dr. C would not have alerted his staff to the real nature of the patient's problem, the close monitoring that would be necessary and the urgent steps to be taken in the event of further bleeding.

Press play for details.

Legal outcomes continued

In his reasons, the judge stated that by these omissions, Dr. B had not met the reasonable standard of care of a prudent physician. Moreover, he stated Dr. B owed the patient a duty to ensure he would be safe during Dr. B's absence and failure to do so was not only an omission but also a failure to discharge a fundamental duty of care to his patient.

Lessons learned

This case highlights the importance of communication when handing over care to another physician.  Consider the following when handing over care:
  • Have you thoroughly explained your patient's condition (including any rare diagnosis) and anticipated treatment plan to the physician to whom you are transferring care?
  • Are you satisfied the physician to whom you are transferring care has the required expertise to manage the patient's condition?
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