Standard 63: Safe Handover

Why it matters. Communication failures during handover are a recognised cause of patient harm. The WHO Patient Safety Curriculum Guide (2007) describes structured handover as a way of reducing omitted information and errors. A standard method means that every clinician knows what to expect, and what to ask.

Sample. Observe handovers on at least two wards on at least two days in the last 3 months, including a shift change, and review the handover records for the same period.

1. Each handover between clinicians uses a structured method.

Method. Observe a sample of handovers and check each against the structure of the method used (SBAR or I-PASS).

Evidence to show. Structured verbal handover (HOS-SOP-004, existing, reused); handover checklist (HND-FRM-001, existing, reused); safe handover procedure (SHO-SOP-001).

Pass when. Every observed handover follows a structured method.

2. Handovers are given face to face or by a call, and recorded.

Method. Check each sampled handover record for the mode of handover and for the time it was given.

Evidence to show. Handover record (HOS-FRM-004, existing, reused); safe handover procedure (SHO-SOP-001).

Pass when. Every sampled handover is recorded with the mode and time.

3. The receiving clinician confirms understanding.

Method. Check each sampled handover for the receiver confirmation, or observe whether the receiver asked the questions the method asks for.

Evidence to show. Structured handover checklist (HND-FRM-001, existing, reused).

Pass when. Every sampled handover has the receiver confirmation recorded.

Immediate fail (any one means the criterion is not met)

• A patient is handed over by a note left at the desk, and the night doctor is not told that the patient has an unstable rhythm.
• A handover is given at the end of a long shift with no structure, and a set blood result is missed.

Why it matters. The information most often missed at handover is the medicines, allergies, set results and the actions still due. Read-back confirms that the receiver heard and understood the key actions, as set out in the WHO Patient Safety Curriculum Guide (2007).

Sample. Review the handover records for a sample of 30 patient handovers in the last 3 months, across all wards.

1. Each handover covers identity, diagnosis, medicines, allergies, risks, set results and due actions.

Method. Check each sampled handover record against the list of required items.

Evidence to show. Structured handover checklist (HND-FRM-001, existing, reused); medicines reconciliation form (HOS-FRM-006, existing, reused).

Pass when. Every sampled handover covers all required items.

2. The receiver repeats back the key actions.

Method. Check each sampled handover for the read-back entry, or observe the read-back in a sample of handovers.

Evidence to show. Structured verbal handover (HOS-SOP-004, existing, reused).

Pass when. Every sampled handover has the read-back recorded.

3. The handover record is signed by both clinicians.

Method. Check each sampled handover for the signatures of the giver and the receiver, with the time.

Evidence to show. Handover record (HOS-FRM-004, existing, reused).

Pass when. Every sampled handover is signed by both clinicians with the time.

Immediate fail (any one means the criterion is not met)

• A patient with a penicillin allergy is handed over without the allergy, and is given the drug on the next shift.

Why it matters. Deterioration often shows before a patient becomes critical. A handover that omits the early warning score or the escalation plan can delay the response to a sepsis or a cardiac event. The WHO Global Patient Safety Action Plan 2021 to 2030 recognises communication at transitions of care as a priority.

Sample. Review the handover records for every deteriorating or high-risk patient handed over in the last 3 months, and observe three bedside handovers.

1. The handover of a deteriorating patient includes the latest observations and the early warning score.

Method. Check each sampled handover of a deteriorating patient for the latest observation set and the score recorded at the handover.

Evidence to show. Vital signs and deterioration response (HOS-SOP-002, existing, reused); early warning score audit record (DET-FRM-001, existing, reused).

Pass when. Every sampled handover includes the latest observations and score.

2. The escalation plan and the named senior clinician are passed on.

Method. Check each sampled handover for the escalation plan and the name of the senior clinician on duty.

Evidence to show. Safe handover procedure (SHO-SOP-001); structured handover checklist (HND-FRM-001, existing, reused).

Pass when. Every sampled handover names the senior clinician and states the escalation plan.

3. The senior clinician is told before the handover ends.

Method. Check the record for the time the senior clinician was told, relative to the end of the handover.

Evidence to show. Safe handover procedure (SHO-SOP-001).

Pass when. Every sampled handover records the senior clinician told before the handover ends.

Immediate fail (any one means the criterion is not met)

• A patient with a rising early warning score is handed over with no escalation plan, and the night team does not call the senior until arrest.

Why it matters. Moves between wards and transfers to other facilities are high-risk points for information loss. A written handover that travels with the patient keeps the medicines, risks and set results together, as recommended in the WHO Patient Safety Curriculum Guide (2007).

Sample. Review the transfer records and the written handovers for every ward move and facility transfer in the last 6 months.

1. Each move or transfer has a written handover that travels with the patient.

Method. Check each sampled move or transfer for the written handover, and that it was sent with the patient.

Evidence to show. Transfer logging, handover and record keeping (AMT-SOP-001, existing, reused); safe handover procedure (SHO-SOP-001).

Pass when. Every sampled move or transfer has a written handover sent with the patient.

2. The handover covers the reason, the diagnosis, the medicines, the allergies, the risks and the set results.

Method. Check each sampled written handover against the list of required items.

Evidence to show. Transfer logging, handover and record keeping (AMT-SOP-001, existing, reused).

Pass when. Every sampled written handover covers all required items.

3. The receiving team confirms receipt.

Method. Check each sampled transfer for the receiving team confirmation and its time.

Evidence to show. Handover at each change of segment (PTR-SOP-007, existing, reused).

Pass when. Every sampled transfer has receipt confirmed with a time.

Immediate fail (any one means the criterion is not met)

• A patient is transferred to another ward with no written handover, and the medicines are not given for two days.

Why it matters. Without audit, a handover problem stays invisible. Regular sampling and review of handover incidents is how a ward finds and fixes weak practice, which is part of the WHO Global Patient Safety Action Plan (2021 to 2030).

Sample. Review the quarterly handover audit results, the handover-related incidents and the agreed actions for each ward in the last 12 months.

1. Handover practice is audited each quarter on a sample of handovers.

Method. Check that each ward has a recorded quarterly audit with a sample size and the results.

Evidence to show. Safe handover audit register (SHO-REG-001); review of falls, pressure injury and handover events (HOV-SOP-001, existing, reused).

Pass when. Every ward has each quarter audited.

2. Each handover-related incident is reviewed.

Method. Check each handover-related incident for a review and its date.

Evidence to show. Review of falls, pressure injury and handover events (HOV-SOP-001, existing, reused).

Pass when. Every handover-related incident has a review recorded.

3. The actions agreed are followed up at the next audit.

Method. Check each agreed action for an owner and a follow-up at the next audit.

Evidence to show. Safe handover audit register (SHO-REG-001).

Pass when. Every agreed action has an owner and a follow-up recorded.

Immediate fail (any one means the criterion is not met)

• Handover failures are found in three consecutive audits, but no action is recorded.