The below article has been reproduced from a BMJ series to help medical students make the leap to budding doctors. The art of effective handover is a neglected topic in medical school. In this article, Richard Beasley and colleagues explain the importance of best practice when exchanging information between healthcare professionals.

Junior doctors working in hospital medicine participate in the handover ritual most days of their working lives. Surprisingly then, this important area of medical practice receives almost no attention in the formal medical curriculum. However attention is now being focused on the importance of communication in ensuring continuity of care.¹ Handover practice has rightly been identified as a key area and has been the subject of three major reports published by healthcare regulators in the United Kingdom and Australia (see below). It is therefore timely to review what constitutes a good handover and to offer some practical suggestions on best practice.

The term handover is used to describe a variety of exchanges of information between healthcare professionals: the formal team meeting, usually held in the morning, where the night staff hand over to the day team; the transfer of information about individual patients between individual doctors which occurs when a patient is referred to another service or transferred to another ward; the briefing of after-hours staff about acutely ill patients to be reviewed and other tasks that need to be done while they are on duty. While each of these situations has a particular requirement, the basic principles of good handover practice can be applied generally. The focus here will therefore be on the formal medical handover in the morning, with the acknowledgement that the principles and processes described also apply to other handover situations.

Benefits of good handover practice

When done well, the handover can be a source of considerable benefit to both patients and doctors. Done badly, it can be the point at which information is lost or distorted, with obvious consequences. The handover can contribute to four main areas.

1. Patients’ safety

Multiple critical incident studies within the healthcare setting and in other fields have shown that poor information transfer is more often a contributing factor to major error than lack of information.^2,3 In hospital medicine, information that needs to be accurately transferred may include mundane clerical facts (such as the fact that there are two Mrs Smiths on a ward or team) as well as relevant clinical information, such as test results. A phenomenon that is often mentioned in these reports is that of the “lost patient”—the one who is missed off the handover list and is therefore not seen on the ward round.

The junior members of the medical team are in the best position to know the details of the patients under their care; we therefore suggest that it is their responsibility to bring this information to the handover. Almost all the literature strongly advocates the use of written lists of patients with relevant clinical details, including critical evening or overnight incidents.⁴ This can be used both as a reminder for the person reporting and as a checklist of tasks to be done by the receiving team. Once they become out of date, these lists should be archived in a secure location—for example, a locked filing cabinet in the handover room. This will prevent breaches of patient privacy generated by lists left lying around the ward. Additionally, in this age of increased litigation, written records give far clearer lines of accountability than accounts of verbal handovers recalled many months later.

2. Patients’ satisfaction

Patients’ confidence in their doctors and the healthcare service as a whole is increased when they do not have to repeat their entire medical history to every doctor who comes to see them.^5,6 It is therefore a courtesy to your patients and your colleagues to give the basic history of all the patients they will see. In the privacy of the handover room, it is possible to ask questions about clinical issues that may generate alarm or discomfort if raised at the bedside.

3. Medical education

The handover can be an important time for clinical education. It is one of the rare opportunities for junior doctors to have the attention of senior staff without the distractions of patients, nurses, and telephone calls. Paying attention to the questions a senior colleague asks about a case can teach one a lot about the general approach to particular clinical scenarios. Bringing an interesting or ambiguous x ray film or test result to a handover can generate an instant second opinion or learning experience. The handover also provides an opportunity to develop the skill of clearly describing cases to other doctors and learning to sift the relevant from the decorative in verbal presentations.^6,7

4. Doctors’ satisfaction

A thorough handover can relieve stress among incoming medical staff because it reduces ambiguity and uncertainty about the tasks to be done. It also reduces stress in the doctor going off duty, who is reassured by the knowledge that responsibility for patient care has been properly transferred. Additionally, it can improve job satisfaction, providing a forum for constructive feedback on recent work.⁶

Tips for good handover practice

Few evidence-based recommendations for good handover practice exist. Recent reports include suggestions on best practice and common pitfalls, however.^4,6,8

The following list is compiled from the common points in these papers and the clinical experience of the authors.

• Set aside adequate time and space
• Minimise distraction—pagers, relatives, unrelated talking
• Have a leader—usually the specialist registrar or consultant
• Receive information actively—ask questions
• Compile a written list of all patients under the care of the team, including location and clinical condition—at least mention everyone
• Maintain an admissions list when on take, preferably in an electronic form
• Bring or have access to relevant x-ray films and results of blood tests—this can be a good task to set medical students attached to your team.

The table below gives a more detailed guide to handing over an individual patient. The example gives the basic written information with the corresponding verbal presentation.

Pitfalls

Several barriers to good handover practice have been identified. It is beyond the scope of this article to consider the remedy for these issues in any detail, but awareness of their existence may help to minimise their occurrence. They include:

• Cultural factors—failure to prioritise handover or an adversarial or bullying climate within medical teams
• Distractions—bleeps, lateness, oversize group
• Incomplete information—includes “dishonest” handover, which seeks to conceal errors or clinical tasks not done as well as “misses” patients or results
• Inadequate follow-up on tasks identified at the handover—this has been identified as a particularly common cause of handover failure
• Focusing on education to the detriment of clinical information.

Conclusion

In the current hospital environment in which junior doctors work, the handover has become an essential part of good medical practice and is beginning to receive critical attention from healthcare managers and providers. To ensure medicolegal requirements are met, dedicated time for the handover is necessary within a junior doctor’s scheduled hours. It is an area to which the junior doctor can make a real and positive contribution for the benefit of their patients and themselves.

The principles described here are based on notions of clear, efficient and honest communication. The rapidly developing field of medical information technology is replacing the handwritten patient list with increasingly sophisticated electronically generated versions,^9,10 but the basic concepts of what constitutes good handover are not affected. They provide the foundation for the development of the handover habit, which if practised regularly will stand one in good stead for one’s working life.

Original authors:
Sharmila Bernau, medical research fellow
Sarah Aldington, senior medical research fellow
Geoffrey Robinson, consultant physician and chief medical officer, Capital and Coast District Health Board
Richard Beasley, consultant physician, Capital and Coast District Health Board, and director, Medical Research Institute of New Zealand, Medical Research Institute of New Zealand, Wellington, New Zealand.

We gratefully acknowledge the BMJ for permission to reproduce this article.

References

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