Hospital doctors raise concern over unsafe patient handover process

Surgical doctors have reported near-misses and various levels of perceived harm to patients due to poor “handovers”.

A “handover” is the term for what happens when a doctor hands over responsibility for the care of a patient to their colleagues.

In a national survey of more than 200 non-consultant hospital doctors (NCHDs), one-third of the surgical doctors surveyed felt the handover process in their current hospital was unsafe.

Within three months of being surveyed, 30pc of the non-consultant surgical doctors reported that a near-miss had occurred as a result of handover.

In all, 16pc reported that handover-related errors resulted in minor harm, while nearly 5pc believed these had resulted in moderate harm.

The survey found 1.5pc of the doctors, or three of the 201 doctors, perceived that patients had experienced major harm or extreme harm due to an inadequate handover in the three months before the survey.

Major harm was defined as major injuries or long-term incapacity or disability requiring medical treatment, while extreme harm is an incident leading to death or major permanent incapacity.

Moderate harm was explained as a significant injury requiring medical treatment but not long-term or permanent; minor harm is an “adverse event leading to minor injury requiring first aid treatment”.

In the Royal College of Surgeons in Ireland (RCSI) study, 85pc reported that information received during handover was missing or incorrect at least some of the time.

They raised concerns from having handovers conducted by text message or WhatsApp or in the hospital coffee shop, to having difficulty accessing functioning computers and printers and other IT issues.

Study co-author Professor Deborah McNamara, vice-president of RCSI and co-lead on the National Clinical Programme for Surgery, said it was easy to underestimate the importance of the conversations that happen when the care of a patient is being transferred from one doctor to another.

“We know that communication errors during the handover process can contribute to adverse outcomes for patients, especially if critical information is omitted,” the consultant surgeon at Beaumont Hospital said.

“Surgical patients are particularly at risk because of the urgency of the care they require, the rapid turnover of patients, and the complex environments where their care is delivered, including emergency departments, critical care units, and the operating theatre.”

The study was based on a 34-question survey carried out online between March and September last year. It found the doctors reported “poor compliance with international best practice for handover and identified potential harms”.

“Process standardisation, appropriate staff training, and the provision of necessary handover-related resources is required at a national level to address this significant patient safety concern,” the researchers said.

In the survey, 28pc of the surgical doctors reported that a patient had been unintentionally missed on the post-take ward round due to inadequate handover within the preceding month.

“Handover practices within Irish hospitals are poorly understood, highly variable, and no previous national audit has been reported,” said the study, which was the largest of its type in Ireland.

In just under half of cases (46pc), the handover was carried out in a dedicated office or tutorial room.

“The majority of remaining locations raised concerns for patient confidentiality, including wards, ward rounds, the emergency department (ED) and hospital coffee shops,” the researchers said.

Despite “several well-established handover guidelines”, the researchers said only 11pc had received formal handover training.

Prof McNamara said they found current handover practices in Ireland had a high risk of error in the national study.

“Junior doctors identified a need for additional supports to reduce the risk to patients that can arise from poor handover practices,” she said.

“This includes things like protected time without distractions or interruptions, better IT resources and more standardised processes to reduce variation in practices between and within hospitals.”

Junior doctors also ­highlighted how much they valued the support of senior colleagues and additional training opportunities in how to perform safer handovers of care.

All senior house officers (SHOs) and registrars working in surgery in Ireland, which totalled 1,084 at the time of last year’s survey, were invited to participate in the 34-question survey; 18pc responded across 11 surgical subspecialities.

Around half (49pc) of these were SHOs while 28pc were specialist registrars; more than half (51pc) were involved with general surgery.

While most handovers took place face-to-face, phone messaging such as WhatsApp or text messages along with phone calls and video calls were used in a minority of cases, raising concern about data protection along with “quality of these handovers”.

In the survey, 37pc of doctors said the handover space was not large enough, 42pc said it was not free from distraction, while 35pc said it was not confidential.

“While electronic systems existed, many NCHDs lacked access to updated patient locating systems, requiring some of them physically attend areas of the hospital to find their patients,” the study said.

Almost all non-consultant ­hospital doctors reported staying beyond their rostered hours to complete handover-related activities.

“While institutional shortcomings play a role in poor compliance, staff accountability cannot be overlooked,” said the researchers.

In replies to open-ended questions, some doctors highlighted a lack of consultant involvement. “It’s not something that is prioritised by consultants, and therefore by the rest of the team,” one said.

Another said there was “no culture within hospital to prioritise surgical handover”, while another observed handovers were “seen as a formality or an annoyance”.

Another said: “Sometimes it is rushed or ignored.”

The study concluded there was poor access to necessary IT resources, a lack of supportive rostering practices such as shift crossover, an absence of protected handover time, and minimal staff training and awareness regarding institutional protocols.

They recommended handover process must involve two-way communication to ensure that a shared understanding has been reached, and “ideally should be face-to-face”.

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