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Handovers


Transferring care to others

Strategies for improving handovers


Patient safety experts have proposed several strategies that have the potential for improving handovers.

Case: Rushed handover
Medical resident

Background

Melissa, a first-year medical resident doing a rotation in cardiology, is on call for the evening. Her senior resident wants to leave for journal club and rushes through the handover on the phone. He tells her about Mr. C, a patient with chest pain who has had blood work, including serial cardiac markers, and a chest x-ray. He tells her that Mr. C can probably be discharged if his work-up is normal.

Medical resident

Clinical events

Eight hours later, Melissa is reviewing Mr. C's bloodwork, which is normal. She is suddenly notified about an unstable patient and quickly discharges Mr. C so that she can take care of the patient's hypotension. She assumes that her senior resident had reviewed Mr. C's chest x-ray, which in fact shows a new right lung mass.
x-ray

Outcome

Unfortunately, there is no follow-up of the chest x-ray finding. Mr. C presents to his family doctor 2 years later with hemoptysis, at which time he is diagnosed with an inoperable lung cancer. He is told that he could have been effectively treated if his previous chest x-ray had been acted upon 2 years earlier.

Think about it

  • What were some of the barriers in this case that contributed to an ineffective handover?
  • What strategies could Melissa and the senior resident have used during the handover to prevent this adverse outcome?

Lessons learned

Handovers are high risk situations
Allow appropriate time for a safe and complete handover of care. Limit the number of interruptions and distractions.

Interactive questioning
Face-to-face exchanges allow for interactive questioning. Be aware of hierarchies that may impede effective communication.

Standardized content
The handover should include a retrospective and prospective view of the patient, along with a recommended plan and clear responsibilities for pending tasks.
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Click below for examples of strategies for improving handovers.

Use the left or right arrow keys for more information.
  • Vitals monitoring screen

    Address the physical environment

    Whenever possible choose a location where the number of interruptions, noise and distractions will be limited during the handover.
  • Blurred clock

    Time constraints

    Consider allowing a designated time for performing handovers and prioritizing your time on the patients who are most sick. Some have found that using a standardized communication tool increases the amount of information transferred without increasing the time to perform the handover [REF]
    Thompson J, Collett L, Langbart M. "Using the ISBAR handover tool in junior medical officer handover: a study in an Australian tertiary hospital." Postgrad Med J, 2011, Vol. 87, p. 340-344.
    . Others have used technology that automatically downloads important patient data into a template to shorten the time spent on team rounds [REF]
    Van Eaton E.G., Horvath K.D., Lober W.B., Rossini A.J., Pellegrini C.A. "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, Vol. 200(4), p. 538-545.
    .
  • Two physicians in discussion

    Communication skills

    Improving communication skills through training can help providers use clear and unambiguous language during handovers. Flattening existing hierarchies for communication may permit a junior member of a team to communicate with the senior members more freely.
  • Two physicians looking at clipboard

    Standardized communications

    Consider using a standardized approach during handover communications that includes a face-to-face verbal interaction whenever possible.

Standardized communications

A structured communication tool could include the following components:
(Read as text only)
Opens in popup
To learn more about standardized communications, click on each box in the diagram.
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What may happen next

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Recommendations

1

History

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Interactive questions

The patient's history including:

  • background information
  • the current situation

Beware of labelling patients

Comments made during handovers may inadvertently contribute to misdiagnosis or inappropriate treatment because of the influence of cognitive biases and stereotyping.

For example, labelling patients as "frequent flyers," "drug seeking," demanding, or histrionic may, in some cases, contribute to an underestimation of the clinical condition.

For more information see the section on Common cognitive biases.