Transfer of care has been defined as “a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location”.¹ It is recognised as a high-risk situation for patient safety, and healthcare professionals have a responsibility to ensure correct and accurate transfer of clinical information.

The State Claims Agency analysed 246 incidents related to transfer of care, identified in one quarter on NIMS, the National Incident Management System. Incidents related to handover of care were common, accounting for 20% of the incidents reviewed. This article, part of a series covering different aspects of transfer of care, focuses on this issue.

Incidents related to handover of care

Analysis of NIMS data shows that incidents related to handover of care occur during transfer of care between departments/services, at clinical handover and between health and social care staff, including ancillary and support staff. Poor handover during transfer of care can result in:

• Suboptimal treatment, where incomplete or inadequate handover was provided, e.g. failure to communicate clinical details, treatment provided prior to or during transfer or infection control status
• Failure to identify or manage a deteriorating patient, where episodes of care (e.g. recording of observations, treatment, or interventions) were not communicated or documented
• Medication error, where medication was omitted, or an extra dose administered because medication administration was not clarified and/or documented at handover
• Clinical care requirements not available, because specific care requirements were not communicated, such as the need for one-to-one special care, pressure ulcer care, or the need for specialist equipment e.g. CPAP (continuous positive airway pressure) machine
• Incorrect patient identification, where patient details were incomplete or incorrect, addressographs and ID bands had incorrect identifiers, or another service user’s details were found in notes
• Poor service user experience, when service users were transferred to a ward not ready to receive them or transferred to incorrect locations

Challenges with handover arise when demands are high, there are capacity issues, time pressures, shift changes, continuous interruptions, and sometimes when health and social care staff are working in circumstances where they may have never met before.

How to improve handover of care

• At handover, communicate, at a minimum, patient identification, clinical history, treatment/interventions undertaken or planned, medication prescribed and administered and any special requirements²

• Standardise the handover process using handover tools or checklists such as ISBAR³ which is a structured tool for communicating critical information and can reduce the risk of errors during handover³

• Where possible, consider having uninterrupted, protected handovers to aid clear communication and delivery of information^2,4

• Implement strategies to gain a good overall sense of the service user, such as a “chart biopsy”, which is the process of selectively examining portions of a service user’s healthcare record to gather specific information about them and a broader sense of the service user and the care they have received⁵

• Ensure documentation / paperwork is present to support the handover process

• Where possible, handover face-to-face rather than by phone to promote positive relationships⁴

• Consider using educational interventions to improve handover – roleplay and simulation of handovers can improve professional relationships, staff confidence, and reduce errors⁶

References available on request.

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