Clinical handover incident reporting in one UK general hospital.

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.

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