Poor handovers still pose significant risk

EARLIER this month the GMC published key findings from its annual National training survey. A total of 51,316 trainee doctors participated – just under three-quarters were in specialty or core training (72 per cent) with 28 per cent of respondents in their foundation training years.

Among the issues of greatest concern was the lack of formal handovers before and after night duty in some hospitals. About a quarter of trainees reported that handovers were "informal" or "not in place" as opposed to "an organised meeting of doctors".

Senior clinicians in supervising roles should take heed of these findings. The GMC in its guidance Leadership and management for all doctors states that doctors "should encourage team members to cooperate and communicate effectively with each other and other teams or colleagues with whom they work. If you identify problems arising from poor communication or unclear responsibilities within or between teams, you should take action to deal with them."

It also states: "You should not assume that someone else in the team will pass on information needed for patient care. You should check if you are unclear about the responsibility for communicating information, including during handover, to members of the healthcare team, other services involved in providing care and patients and those close to them."

Failures in handover have been indentified as a major cause of preventable patient harm in numerous studies – leading to delayed and incorrect diagnoses, repeated investigations and incorrect treatment. One study published in 2007 found that over a typical weekend in which there may be as many as five shift handovers, only 2.5 per cent of information is retained at the final handover if there has been no written record. In contrast if notes are taken, 85.5 per cent of information is retained and 99 per cent when a standardised proforma is used.

In April 2010 the Royal College of Physicians carried out a survey of consultants and trainees in support of the development of an acute care toolkit for handovers. It found that handovers are predominantly verbal, with just over half involving additional written communication. Permanent records are uncommon (only about 20 per cent) and handover processes are rarely the subject of audit (only 10 per cent). It also found that 34 per cent reported that handovers were not timetabled into work patterns and only 33 per cent reported that handovers were conducted well, though 72 per cent believed it an important issue.

Poor communication and handovers between doctors are common factors in clinical negligence and regulatory actions encountered at MDDUS. A lack of clear written notes poses a fundamental medico-legal problem in itself as actions not recorded are difficult to prove.

MDDUS supports the RCP in efforts to improve the quality of handovers and encourages members to consult the RCP toolkit which provides "a framework for standardisation of clinical handover practice, audit and monitoring of the process, and defining accountability and responsibilities in the process".

It states that a standardised clinical handover should:

• be embedded in hospital policy and culture
• involve training in handover and communication (induction agenda, cross-professional education)
• be tailored to local/unit needs, e.g. different priorities in A&E, acute assessment unit (AAU), general ward handovers
• be recognised as a multiprofessional team activity, reducing repetition
• command designated time and location within the job plan/shift patterns
• determine clear arrangements for ongoing care of patients
• define who must be present, including senior (consultant) staff.

Access the toolkit at the RCP website.

ACTION Supervising clinicians and trainees have a key responsibility to conduct and record clinical handovers at a sufficient standard to ensure patient safety. Failings can result in both legal and regulatory action.