In medicine, we use the Swiss-cheese model to explain how mistakes can be made and how they can be stopped.
Put simply, there are layers of defence against mistakes being made, but none of these are perfect, so each has holes.
When these holes in defences are lined up, a mistake is made. Handover is one of these layers of defence against mistakes.
Handovers can take many forms, from quick handovers on the phone from the day team on wards to the night team covering the whole hospital, to pieces of paper the ward teams supply to the weekend team highlighting urgent jobs and sick patients.
At the moment, I am working in acute medicine, where handovers happen twice a day for the on-call team. Rather than explaining how important the handover slice of cheese is, I’m going to use some examples (all are fictional patients, and handovers, but based on real handovers).
Margaret Jones, ward 3b
Repeat U&E, FBC, CRP and act accordingly. So, you sit down on a Saturday morning, at the start of a 12.5 hour shift and flip through the printed handovers from the ward teams and see this. This is a patient you have never seen before and have no idea what you are looking for in their blood tests. Have they had something wrong that needs monitoring? Are these routine blood tests that just need quickly checking? Are they urgent or life threatening? You have no way of knowing, so off you trot to ward 3b to plough your way through the notes to find out why these blood tests were so important.
Review ABG, may need non-invasive ventilation. This type handover should hopefully be done verbally to ensure the team picking up this patient’s care is aware of the urgency of the situation. This handover doesn’t relay how sick this patient is. Are they struggling and may need to be urgently reviewed for higher level care? Or are they in fact already in a place where they can be closely monitored? Also, there’s no location of the patient. Let the hunting begin.
Alice White, ward 7 bed 4c
Cardiac failure, acute kidney injury, hyperkalaemia, DNACPR in place, not for ITU. Review U&Es, and overall patient. Manage K and fluids, may be palliative, discussion has been had with family. This is a good handover; we like these. Not only does it have the patient’s age, location, and medical history, exactly what the ward team would like to happen and why is outlined, alongside making it clear that a discussion with the patient’s family has already been had, taking some pressure off the weekend team if the patient is deemed to be at the end of life. We all get taught at medical and nursing school how to do a good handover over the phone, using a standard approach, usually an SBAR, but very little (if any) time is spent on written handovers, which are used across all hospitals.
Key information that I would like to have in all handovers, not just written, is:
- Patient details including age, location, and hospital identifier
- Past medical history
- Current reason for admission
- The job(s) that you would like done and how to act on them e.g. ‘review U&Es, and replace potassium as needed’, rather than ‘review U&Es’.
People make mistakes, everyone knows that it happens, however a good handover – be it verbal, or written – will mean there are fewer holes for mistakes to fall through, and the team you’re handing over to will thank you for giving them a complete handover.
I’d be interested in hearing your thoughts and if you have any tips for a good handover!
Stephanie Rees is a foundation year 1 trainee and member of the BMA Welsh junior doctors committee