BMJ j4328 Full

BMJ 2017;359:j4328 doi: 10.1136/bmj.
j4328 (Published 2017 October 09) Page 1 of 5
Practice
BMJ: first published as 10.1136/bmj.j4328 on 9 October 2017. Downloaded from http://www.bmj.com/ on 12 May 2024 by guest. Protected by copyright.
PRACTICE
ESSENTIALS
Safe handover
1
Hanneke Merten researcher in quality and safety in healthcare , Louise S van Galen research fellow
2
in patient safety in the acute healthcare chain , Cordula Wagner director of NIVEL, professor of
1 3
patient safety
1
Department of Public and Occupational Health, VU University Medical Centre, van der Boechorststraat 7, 1081 BT Amsterdam, Netherlands;
2
Department of Internal Medicine, VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands; 3NIVEL, Otterstraat
118-124, 3513CR Utrecht, Netherlands
High quality handovers are essential for safe healthcare and are structured handover tools improved information transfer and
used in many clinical situations. Miscommunication during increased professional satisfaction. Shift-to-shift handovers at
handovers can lead to unnecessary diagnostic delays, patients the bedside instead of away from the patient also improved
not receiving required treatment, and medication errors.1 satisfaction for patients and staff in a systematic review which
Miscommunication is one of the leading causes for adverse included 41 studies.10 Another systematic review of 10 studies
events resulting in death or serious injury to patients.2 The showed that educational interventions and non-technical skill
process of handovers can be improved, and the aim of this article based approaches to improve handovers such as simulation,
is to provide practical guidance for clinicians on how to do this group discussions, and lectures were beneficial.11
better.
What is a handover? What is best practice internationally?
In 2007 the Joint Commission International (JCI) and the World
A handover involves the transfer of professional responsibility
Health Organization suggested implementation of a standardised
and accountability for some or all aspects of care for a patient,
approach to handover communication by using the SBAR
or groups of patients, to another person, such as a clinician or
(Situation, Background, Assessment, Recommendation)
nurse, or professional group on a temporary or permanent basis.3
technique.12 13 Effective communication is one of the JCI’s main
Ideally a professional can take over responsibility for a patient
patient safety goals and one of the elements assessed during
only if he or she receives all relevant information to continue
hospital accreditation. Handover needs to fulfil the criteria of
the treatment or care effectively and safely.
being timely, accurate, complete, unambiguous, and understood
by the recipient.14 Guidance is available to help clinicians
How common are handovers? improve handovers (see box 1 and additional educational
Patients can be handed over up to 15 times during a five day resources).15
hospitalisation, and a doctor might participate in 3000 handovers
a month.4Figure 1⇓ illustrates the potential handover interactions How to do it better
for patients in an acute setting.
Changing handover practice at an organisational level is
complicated and requires effective strategies for implementation,
Why is handover important? reinforcement, and education on why it is important.11-17
A narrative review including 69 studies and systematic review Nevertheless, everyone can work on their handover practice by
of 38 studies showed that poor communication between team taking some practical steps that are relevant to all types of
members can lead to errors, patient harm, discontinuity of care, handovers. These include
inefficient use of resources, and dissatisfied patients.5 6 There • Assessing the key people that need to be involved in the
are several well studied ways to improve handovers. Systematic handover (physicians, nurses, and patients and their carers)
reviews of 36 quasi-experimental or observational studies7 and
• Choosing a calm environment with minimal distractions
29 studies (two randomised controlled trials and 27 uncontrolled
studies)8 and an intervention study9 showed that implementing • Using a structured format such as SBAR
Correspondence to: H Merten [email protected]
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BMJ 2017;359:j4328 doi: 10.1136/bmj.j4328 (Published 2017 October 09) Page 2 of 5
PRACTICE
What you need to know

• Information shared during clinical handover includes, as a minimum, the patient’s current health status, medications, and treatment
plans as well as advance directives and any important changes in the patient’s status
• Tools and handover structures such as SBAR (Situation, Background, Assessment, Recommendation) have been shown to improve
the quality of handovers
• Involving patients and carers in handovers—including scheduling a timely discharge conversation to discuss aspects of their admission
and follow-up plan that includes a personalised discharge letter—is of great value.
Sources and selection criteria

We searched PubMed and the Cochrane review library (until April 2017) to identify original research studies for clinical handovers and the
effectiveness of tools to improve handovers. We searched Medline using the MeSH term “patient handoff” with all related terms in the MeSH
hierarchy (such as handover). This resulted in 626 potentially relevant papers. Additionally, we used the general search term “clinical
handover” which resulted in 1206 potentially relevant papers. Titles were scanned to search for relevant review studies on intrahospital
handovers, (electronic) handover tools, interdisciplinary communication, handovers to and from the hospital, and patient involvement in
handovers.
We also searched the internet for reports, protocols, guidelines, and practical communications on handovers. Our personal network within
the patient safety field was used to investigate the daily practice in handovers.
Box 1: What tools can help improve handover?

The use of structured handover tools, such as SBAR13 or I-PASS (Illness severity, Patient summary, Action list, Situation awareness and
contingency plans, and Synthesis by receiver)9 have been shown to improve information transfer and healthcare professionals’ satisfaction
with handovers.7 8 The clinical questions included within the fixed format of a handover tool can be decided on at an organisational level or,
depending on the type of handover, department, patient group or individual user. An example of SBAR is shown in box 2.
Box 2: Example of SBAR structure for telephone consultation between resident and senior staff member
Situation—A concise statement of the problem (what is going on now)
“I am calling about Mrs Smith; she is on the orthopaedic ward. I have seen her five minutes ago and she was dyspnoeic, breathing
heavily, and had difficulty finding words.”
Background—Pertinent and brief information related to the situation (what has happened)
“She is six days postoperative after total hip surgery, wound is healing. She is not fully mobile yet. Fraxiparine 0.3 cc, no diuretics, 1 L
NaCl IV, no allergies, normal infection parameters. Vital functions: blood pressure 110/75 mm Hg, pulse 105 beats/min, temperature
37.8°C, breathing frequency 35breaths/min, oxygen saturation 88%, no additional oxygen. She has a history of cardiac problems, but
exact details not known.”
Assessment—Analysis and considerations of options (what you found or think is going on)
“Patient is deteriorating rapidly, she has severe problems with breathing; her breathing is shallow, and her lips are pursed. I think she
might need artificial respiration or additional diagnostics to find out the cause.”
Recommendation—Request or recommend action (what you want done)
“I am worried and want you to come to the ward immediately for a second assessment of Mrs Smith. Is there anything I should do in
the meantime?”
• Providing the person you are handing over to with the What is the best approach to handover
opportunity to ask questions and checking if they have between hospitals and community settings?
understood correctly (report back). For handovers at discharge, several important elements have
been identified.14 19 Start planning the discharge early and
What is the best approach to handover in a structure the discharge process so everyone knows what to
hospital setting? expect in terms of responsibilities, coordination of tasks within
Schedule sufficient time for the handover adjusted to the the team, and content of discharge information. The medical
complexity of the patient’s situation. Start by introducing discharge information for a patient should at least include active
yourself and create an environment in which participants feel problems, diagnosis, medications, any services required, warning
free to ask questions. Emphasise important elements during signs of a worsening condition, safety-netting (who to contact
your handover, such as expected actions within the next shift in case of an emergency), and a follow-up plan. Involve the
or details of any treatment restrictions such as avoiding giving patient and carer in the discharge by providing verbal
fluids. When handing over to a team of care professionals, give information during a discharge conversation and written
specific orders to every individual. Check if the receiver of the information in a personalised patient discharge letter with
handover has understood the information correctly by asking information on diagnosis, treatment, potential complications,
them to report back, and record necessary information in the medication, lifestyle advice, and who to contact with questions.20
patient’s record. Be aware of barriers for effective Aim to send the (preliminary) discharge letter to the community
communication when multiple disciplines are involved, such care professional in good time, and, if possible, call to inform
as differences in training, communication styles, lack of them if you feel this might enhance safe handover.
confidence, and hierarchy.18 Standardised handover tools and
simulations may help to overcome these.18 How should I involve patients in handovers?
The patient is the only constant factor in the care process and
can therefore provide valuable information during the handover
PRACTICE
process. Commonly used tools to structure handovers usually 3 British Medical Association. Safe handover: safe patients. Guidance on clinical handover
for clinicians and managers. BMA, 2004.
do not include patient involvement; therefore, you need to 4 Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in
incorporate this as an additional element. Keep in mind that, as academic medical centers: strategies for a safe and effective resident sign-out. J Hosp
Med 2006;359:257-66. doi:10.1002/jhm.103 pmid:17219508.
a patient receives an overwhelming amount of information
5 Vermeir P, Vandijck D, Degroote S, et al. Communication in healthcare: a narrative review
during admission, having a carer present during the handover of the literature and practical recommendations. Int J Clin Pract 2015;359:1257-67. doi:
10.1111/ijcp.12686 pmid:26147310.
can be valuable. Try to involve the patient and carer whenever 6 Nagpal K, Vats A, Lamb B, et al. Information transfer and communication in surgery: a
possible; not only during the more informal moments when systematic review. Ann Surg 2010;359:225-39. doi:10.1097/SLA.0b013e3181e495c2 pmid:
20647929.
talking to the patient at the bedside, but also during formal 7 Abraham J, Kannampallil T, Patel VL. A systematic review of the literature on the evaluation
handovers. of handoff tools: implications for research and practice. J Am Med Inform Assoc
2014;359:154-62. doi:10.1136/amiajnl-2012-001351 pmid:23703824.
Establish individual patients’ need, wishes, and capacity for 8 Robertson ER, Morgan L, Bird S, Catchpole K, McCulloch P. Interventions employed to
participation and understanding during the handover process, improve intrahospital handover: a systematic review. BMJ Qual Saf 2014;359:600-7. doi:
10.1136/bmjqs-2013-002309 pmid:24811239.
and discuss the level of involvement that they feel comfortable 9 Starmer AJ, Spector ND, Srivastava R, et al. I-PASS Study Group. Changes in medical
with.21 Patients can be more actively involved by conducting errors after implementation of a handoff program. N Engl J Med 2014;359:1803-12. doi:
10.1056/NEJMsa1405556 pmid:25372088.
handovers at the bedside, providing the patient with 10 Mardis T, Mardis M, Davis J, et al. Bedside shift-to-shift handoffs. A systematic review of
understandable information about their condition and treatment the literature. J Nurs Care Qual 2016;359:54-60. doi:10.1097/NCQ.
plan, and allowing them to ask questions.22 For this to succeed, 0000000000000142 pmid:26192148.
11 Gordon M, Findley R. Educational interventions to improve handover in health care: a
aim to set a specific time and place so patient and carer(s) know systematic review. Med Educ 2011;359:1081-9. doi:10.1111/j.1365-2923.2011.04049.
when to expect you. Create a situation in which patients feel x pmid:21933243.
12 WHO Collaborating Centre for Patient Safety Solutions. Communication during patient
comfortable to participate, for example, by introducing yourself, hand-overs. WHO, 2007. www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.
sitting down instead of standing next to the patient, making eye pdf.
13 Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving
contact, and encouraging questions. Protect patients’ privacy communication between clinicians. Jt Comm J Qual Patient Saf 2006;359:167-75. doi:10.
during bedside handovers by avoiding discussing sensitive issues 1016/S1553-7250(06)32022-3 pmid:16617948.
14 Joint Commission International. Accreditation standards for hospital. Joint Commission
in front of other patients in the room. International, 2010.
15 Australian Medical Association. Safe handovers: safe patients. Guidance on clinical
Contributors: HM conducted the literature search, talked to two patients, handover for clinicians and managers. Australian Medical Association, 2006.
16 Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. Introduction of surgical
and wrote the first draft of the manuscript. LSG and CW critically revised safety checklists in Ontario, Canada. N Engl J Med 2014;359:1029-38. doi:10.1056/
the manuscript for important intellectual content. All authors commented NEJMsa1308261 pmid:24620866.
17 Borchard A, Schwappach DL, Barbir A, Bezzola P. A systematic review of the effectiveness,
on and revised subsequent drafts and approved the final version of the compliance, and critical factors for implementation of safety checklists in surgery. Ann
manuscript. Surg 2012;359:925-33. doi:10.1097/SLA.0b013e3182682f27 pmid:22968074.
18 Foronda C, MacWilliams B, McArthur E. Interprofessional communication in healthcare:
Competing interests: We have read and understood BMJ policy on An integrative review. Nurse Educ Pract 2016;359:36-40. doi:10.1016/j.nepr.2016.04.
declaration of interests and have no relevant interests to declare. 005 pmid:27428690.
19 The Joint Commission. Hot topics in health care. 2012. Transitions of care: the need for
Transparency: HM is guarantor for the manuscript and affirms that the a more effective approach to continuing patient care. The Joint Commission, 2012.
manuscript is an honest, accurate, and transparent account of the study 20 Buurman BM, Verhaegh KJ, Smeulers M, et al. Improving handoff communication from
hospital to home: the development, implementation and evaluation of a personalized
being reported; that no important aspects of the study have been omitted; patient discharge letter. Int J Qual Health Care 2016;359:384-90. doi:10.1093/intqhc/
and that any discrepancies from the study as planned have been mzw046 pmid:27224995.
21 Flink M, Hesselink G, Pijnenborg L, et al. HANDOVER Research Collaborative. The key
explained. actor: a qualitative study of patient participation in the handover process in Europe. BMJ
Qual Saf 2012;359(Suppl 1):i89-96. doi:10.1136/bmjqs-2012-001171 pmid:23112290.
Provenance and peer review: Commissioned; externally peer reviewed.
22 Manias E, Watson B. Moving from rhetoric to reality: patient and family involvement in
bedside handover. Int J Nurs Stud 2014;359:1539-41. doi:10.1016/j.ijnurstu.2014.08.
1 Australian Commission on Safety and Quality in Health Care. Implementation toolkit for 004 pmid:25200387.
clinical handover improvement. ACSQHC, 2012.
Published by the BMJ Publishing Group Limited. For permission to use (where not already
2 The Joint Commission. Sentinel event data: root causes by event type. The Joint
granted under a licence) please go to http://group.bmj.com/group/rights-licensing/
Commission, 2016.
permissions
PRACTICE
Additional educational resources

• Royal College of Physicians. Acute care toolkit 1: Handover. www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit-1-handover
– Several tools and worksheets available. No registration required
• Australian Commission on Safety and Quality in Health Care. Commission has several publications, resources, and educational tools
for clinical handover improvement. No registration required
– Clinical handover. www.safetyandquality.gov.au/our-work/clinical-communications/clinical-handover/
– Implementation toolkit for clinical handover improvement. www.safetyandquality.gov.au/implementation-toolkit-resource-portal/
– Standard 6: Clinical handover. Safety and quality improvement guide. www.safetyandquality.gov.au/wp-content/uploads/2012/10/
Standard6_Oct_2012_WEB.pdf
• Institute for Healthcare Improvement. SBAR toolkit. www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx
– Provides several practical tools such as the SBAR communication tool, scenarios, lesson plans, and tips for using SBAR. Registration
required
• Australian Medical Association. Safe handover: safe patients. Guidance on clinical handover for clinicians and managers. https://ama.
com.au/sites/default/files/documents/Clinical_Handover_0.pdf
– Provides guidance for safe clinical handovers for clinicians and managers. No registration required
• HANDOVER Project. http://handover.cmj.org.pl
– Contains a handover toolbox and a library with handover publications. Registration is required for the handover toolbox
• I-PASS Study Group. http://www.ipasshandoffstudy.com/home
– Information about the I-PASS handover study. Registration is required for request of curriculum materials
Information source for patients

The Guy's and St Thomas' safety card. www.guysandstthomas.nhs.uk/patients-and-visitors/patients/inpatients/safety-card.aspx
• An example of a patient safety card that can support patients to take responsibility for their own care and safety, including items to
discuss with nurses and physicians. No registration required
Patient involvement in handovers: a carer’s story (HM)

Our son was born in October 2016 during a rapid delivery after a 42 week pregnancy. Immediately after birth, our son had difficulty breathing.
Adequate action was taken and, after some complications, he made a steady recovery, and we were discharged five days later.
During our admission, all staff was friendly and concerned with our wellbeing. However, we had difficulties getting to grips with the whole
situation. In my opinion, one contributing factor was that we, as parents, were never aware of or included in any shift-to-shift handovers
between the nurses and between the physicians. We had too little information and were constantly asking nurses and physicians questions,
but the information provided was very fragmented. We had to tell our story multiple times during the admission, and we sometimes had to
remind nurses and physicians of intended actions suggested by the previous shift. This did not make us feel confident about the system as
it felt inefficient.
In my opinion, not including us in the handover process was a missed opportunity because we could have provided additional information
and perhaps facilitated the care process.”
Education into practice

• Are staff in your hospital, practice, or department explicitly trained in conducting handovers with a structured handover tool such as
SBAR?
• How do you create a facilitating environment for handovers?
How patients were involved in creation of this article

During the planning of this article we asked three patients about their experiences in handovers:
• None of them was actively involved in the day-to-day handover process
• All said that it could be difficult to understand the information provided by care professionals, such as about treatment plans, medication,
and what to expect
• Two would have preferred to receive more information, but the other patient had no desire to be more actively involved.
Figure
PRACTICE
Fig 1 Handover points from home to hospital, within the hospital, and from hospital to home for a patient with an acute
illness (adapted with permission from design by LS van Galen for her thesis “Patient Safety in the Acute Healthcare Chain:
is it safer@home?”)

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BMJ 2017;359:j4328 doi: 10.1136/bmj.

j4328 (Published 2017 October 09) Page 1 of 5

Correspondence to: H Merten [email protected]

What you need to know

Sources and selection criteria

Box 1: What tools can help improve handover?

Additional educational resources

Information source for patients

Patient involvement in handovers: a carer’s story (HM)

Education into practice

How patients were involved in creation of this article

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