OBJECTIVE: To determine the prevalence and characteristics of clinical handover incidents that occurred across a medium-size UK hospital. DESIGN: A retrospective review of 36 consecutive months of data from the hospital electronic database of critical incidents was conducted. MAIN OUTCOME MEASURES: Number of incidents reported, characterization of handover incidents according to clinical setting, severity and type of incidents. RESULTS: We identified 334 handover incidents. The number of reported incidents increased over the 3 years. The transfer of patient care within the same specialty accounted for 51% (170) of incidents of which 75% (143) occurred during a change of shift. The specialties reporting the highest number of adverse events were: Obstetrics and Gynaecology, 42% (140); Medicine for the Elderly, 12.2% (41) and General Medicine, 12% (40). The most common types of handover incident scenario were poor or incomplete handover, 45% (151) and no handover of a patient at all, 29% (98). Reported severity was generally low (99%). CONCLUSIONS: Current reporting rate is low if compared with prospective studies highlighting an issue of under-reporting. Many incidents appear to be of modest harm for patients because of response time; however, further research is required to assess potential severity and level of harm linked to low-quality handovers.
OBJECTIVE: To determine the prevalence and characteristics of clinical handover incidents that occurred across a medium-size UK hospital. DESIGN: A retrospective review of 36 consecutive months of data from the hospital electronic database of critical incidents was conducted. MAIN OUTCOME MEASURES: Number of incidents reported, characterization of handover incidents according to clinical setting, severity and type of incidents. RESULTS: We identified 334 handover incidents. The number of reported incidents increased over the 3 years. The transfer of patient care within the same specialty accounted for 51% (170) of incidents of which 75% (143) occurred during a change of shift. The specialties reporting the highest number of adverse events were: Obstetrics and Gynaecology, 42% (140); Medicine for the Elderly, 12.2% (41) and General Medicine, 12% (40). The most common types of handover incident scenario were poor or incomplete handover, 45% (151) and no handover of a patient at all, 29% (98). Reported severity was generally low (99%). CONCLUSIONS: Current reporting rate is low if compared with prospective studies highlighting an issue of under-reporting. Many incidents appear to be of modest harm for patients because of response time; however, further research is required to assess potential severity and level of harm linked to low-quality handovers.
Authors: Anita Romijn; Martine C de Bruijne; Pim W Teunissen; Christianne J M de Groot; Cordula Wagner Journal: BMJ Open Date: 2016-07-14 Impact factor: 2.692