Guiding Principles and Related Data Items for Safer Handover

Background
Inadequate communication during patient handovers is recognised in England
and internationally as a major contributory cause of patient safety incidents and
patient harm. Poor communication at handover also contributes to many
difculties and delays experienced by health care professionals. Handover of
patient care has been highlighted as a high risk transaction by organisations
including the ational Patient !afety "gency #P!"$
i
% the &orld Health
'rganisation #&H'$
ii
and the "ustralian (ouncil for !afety and )uality in Health
(are
iii
. *he &H' emphasises that +gaps in communication can cause serious
breakdo,ns in the continuity of care% inappropriate treatment% and potential
harm to the patient-.
*he (linical !afety *eam of the .epartment of Health Informatics .ivision #.HI.$
,hich ,as previously part of H! (onnecting for Health #H! (/H$% has
developed key guiding principles and related data items to be used for all types
of clinical handover. *he guiding principles and related data items are the
product of evidence from the P!"% the &H' and other international bodies and
research H! (/H commissioned from the (entre for Health (are Informatics
.esign at (ity 0niversity
iv
. *hey take the form of a combination of three key
guiding principles and eight related data items. *he data items are about
accurate patient identi1cation% coupled ,ith questions #for ,hich guidance ,ill
be provided$ ,hich ,ill give information that must be included in transfer of
information at handover. *hese guiding principles and the related data items are
the subject of this consultation.
Explanation of Guiding Principles
*he guiding principles for safer handover set the context for the use of the
related data items.
*here are three key guiding principles2
the data items constitute a core set of issues ,hich must be used in any
and every clinical handover3
the core set of issues is necessary% but not sufcient for any and every
clinical handover 4 each health care setting ,ill have its o,n% additional
set of essential data items to be transferred in a clinical handover3
the guiding principles and related data items for ensuring safer clinical
handovers are additional to% and not instead of, all usual clinical safety
5
assurance measures as set out in .ata !et (hange otices #.!(s$
567899:
1
and 5;7899:
2
.
Academy of Medical Royal Colleges AoMRC! standards for medical records
*he "o<=( endorsed national standards for structure and content of medical
documentation at admission% handover and discharge illustrate an expression of
the handover guiding principles and use of related data items in practice
#,,,.rcplondon.ac.uk7resources7clinician>E8>;9>::s?guide?record?standards?
>E8>;9>:@?part?8?standards?structure?and?content?medical?record$.
e, core clinical headings for electronic record systems% conforming to the
guiding principles% ,ill shortly be published. *hey ,ill support the handover
process and provide a record of ,hat ,as communicated at handover. <any
healthcare settings ,ill have discipline or setting speci1c essential additional
data items to be transferred in the handover. *he core content is designed to be
supplemented ,ith those data items% as appropriate to each care setting.
"#y t#e Healt# Informatics $nit HI$! of t#e Royal College of P#ysicians is
conducting t#e consultation on t#e guiding principles and related data items
*he .HI. (linical !afety *eam has been ,orking ,ith the HI0 on the guiding
principles and related data items because of the close links bet,een them and
the "o<=( national standard headings. Aecause the HI0 led the development of
the "o<=( standards% it has ,orking relationships ,ith the professional
organisation of all the clinical disciplines. /or this reason the HI0 agreed to carry
out the multi?professional consultation on the guiding principles and related data
items ,ith those professional organisations.
%#e Data Items &#ic# Relate to t#e Guiding Principles
"ll clinical handovers of patient care should include records that travel ,ith the
patient and contain the follo,ing data items ,hich relate to the guiding
principles2
ame # Blast nameC and B1rst nameC as endorsed by the I!A standard
967899: $
.ate of Airth #.'A$
H! umber
1
*his standard speci1es the risk management processes required to minimise risks to
patient safety in respect to the manufacture of health soft,are products either as ne,
systems or as changes to existing systems.
2
*his standard speci1es the risk management processes required to minimise risks to
patient safety in respect to the deployment and use of soft,are products either as ne,
systems ,ithin a health organisation or as changes to an existing systems environment.
8
&hat is ,rong ,ith this patientD e.g. "ctive (linical Problems
&hat has been doneD E.g. =elevant Investigations E *reatments to date
&hat needs to be doneD E.g. "ction plan 4 including ,hen and by
,hom.
"nything else I should kno,D 7 "lerts e.g. risks% allergies% statuses%
disability etc.
=esponsible consultant7team7clinician e.g. FP making the handover
Proposed additional items
=esponsible consultant7team7clinician e.g. FP to ,hom the handover is
being made
Fuidance on a number to use ,hen the H! umber is not available 4
e.g. person becomes unconscious in the street
v

<edications 4 current
COT response 15 May 2012
5. .o you agree ,ith the general approach of using guiding principles and
related data items as set out in the consultation paperD GE!
8. .o you agree ,ith the follo,ing guiding principlesD
*he data items constitute a core set of issues information ,hich must be
used in any and every clinical handover
the core set of issues information is necessary% but not sufcient for any
and every clinical handover 4 each health care setting ,ill have its o,n%
additional set of essential data items to be transferred in a clinical
handover
the guiding principles and related data items for ensuring safer clinical
handovers are additional to% and not instead of% all usual clinical safety
assurance measures as set out in .ata !et (hange otices #.!(s$
567899: and 5;7899: GE!
@. .o you agree ,ith the follo,ing related data itemsD
ame # Blast nameC and B1rst nameC as endorsed by the I!A standard
967899: $
@
.ate of Airth #.'A$
H! umber
&hat is ,rong ,ith the patient e.g. "ctive (linical Problems
&hat has been done. E.g. =elevant Investigations E *reatments to date
&hat needs to be done. E.g. "ction plan 4 including ,hen and by ,hom.
"nything else that should be kno,n 7 "lerts e.g. risks% allergies% statuses%
disability etc.
=esponsible consultant7team7clinician e.g. FP making the handover
GE!
6. .o you agree ,ith all of the three suggested additional data itemsD
=esponsible consultant7team7clinician e.g. FP to ,hom the handover is
being made
Fuidance on a number to use ,hen the H! umber is not available 4 e.g.
person becomes unconscious in the street
<edications 4 current GE!
H. "re there any other data items you think should be included in the guiding
principles for all handoversD GE!
ext of kin% and contact number
'ther services currently involved% e.g. social services% mental health%
probation% drug and alcohol.
(hris "ustin
=esearch and development ofcer
(ollege of 'ccupational *herapists
6
i
Safe handover: safe patients. Guidance on clinical handover for clinicians and managers (2004). London: NPSA,BMA
and Modernisation Agency
ii
Communication During Patient and!"vers WHO ! Patient Safety Solutions, volue 1, solution !, May 2""#
iii
"SS#$ Guide to Clinical andover #mprovement. Australian $oission on Safety and %uality in Healt& care' Marc&
2""(
iv
%S C& Safer andover Pro'ect: $(!0)!0*00 ! &inal (eport on Safer andover + $entre for Healt& $are )nforatics
*esign, $ity +niversity, London' ,uly 2""(
v
Guidance from the %PS, sa-s that .here the %S %um/er is not availa/le0 a hospital num/er or emergenc-
num/ering should /e used until the %S %um/er is availa/le.