Research shows that poor handover in hospitals puts patients at risk of severe harm

Summary

Research undertaken by digital health platform, CAREFUL shows that handover in hospitals is the cause of frequent and severe harm to patients.

Content

Handover in hospitals is the cause of frequent and severe harm to patients, according to new research* by digital health platform, CAREFUL. Many patients are suffering because handover is poorly controlled and under-recognised as a source of clinical risk.

Handover is the transfer of responsibility and crucial patient information between practitioners and teams. Handover takes place when shifts change and when patients are transferred between departments or outside of the hospital into another care setting. This is a time when staff are under pressure and when mistakes can happen – as the research shows.

“We undertook this research because little is known about how practitioners see the risks of handover and the impact of handover on patient safety,” says CAREFUL CEO, Dr DJ Hamblin-Brown. “We anticipated that doctors and nurses would report some errors, but the frequency with which harm is reported across the world is disturbing.”

Patient safety in operating theatres has been a recognised problem for many years – ever since the publication of the original checklist article in the New England Journal of Medicine. By contrast, handover, despite being possibly the most common clinical process across healthcare, has not been studied so widely.

CAREFUL’s research investigated clinicians’ experience of handover, receiving 432 completed responses from clinicians in 26 countries via an open, anonymous and confidential online questionnaire. Published in February 2022, the findings revealed that errors in handover occur weekly or daily, according to 12% of respondents. Nearly 10% had witnessed severe harm – either death or otherwise life changing – because of handover error.

“Handover takes place about 4,000 times each day in a typical teaching hospital”, explains Dr Hamblin-Brown. “It is a procedure prone to a multitude of errors due to reliance on paper that’s easily lost or verbal discussion that’s easily forgotten.”

One of the most worrying findings in the research is that most handover takes place using a many different support systems; 35% are still using handwritten notes; 21% are using office documents such as Word and Excel; 10% write on whiteboards and a full 15% are using unofficial messaging apps like WhatsApp.

Healthcare leaders reflect the same concerns as staff, but they specifically also want more access to patient information and better electronic systems. Digital platforms may be the only real solution to the challenges surrounding handover, with the ability to provide safe and secure access to handover information at the swipe of a screen that is neither lost nor forgotten.

“We work in an industry that is failing to take seriously the dangers of handover. It is arguably the most common, and one of the most important, processes. We harm both staff and patients if we fail to address the dangers of handover,” concludes Dr Hamblin-Brown.

*This paper is in pre-print and has not yet been peer-reviewed.