Handover

A handover is a structured transfer of patient information from one team to the next at a change of shift or rotation.

• Harm at handover comes from information never said, never written, or never confirmed.
• Adverse events affect about 1 in 13 admissions; over a third are preventable (Canadian Adverse Events Study, 2004).
• A structured handover cut medical errors by 23% and preventable harm by 30% without taking longer (I-PASS, 2014).
• Two parts, always: written and verbal.

• Four team skills: clear roles, situation monitoring, mutual support, closed-loop communication (TeamSTEPPS).
• Place and time: quiet, fixed, uninterrupted.
• Roles: who presents, who writes, who takes the tasks.
• Sickest first: unstable patients and anyone needing a decision tonight.
• Receiver is active: ask, confirm the numbers, repeat the plan back.
• Hierarchy: the junior asks, the senior answers.
• Fatigue: write it down before you say it.

The written handover is the last progress note, in SIGNOUT order. It is the record; the call is the explanation.

• R1 and R2: write the final progress note for every patient as the sign-out, then tell the R3 and R4 registrars.
• R3 and R4: verbal handover to the incoming registrars, by phone or as a group.
• Pending results, open consults and anything due tonight go in writing, with who to call.

Written sign-out skeleton

S: sick / watcher / stable · DNR or ceiling of care
I: age, sex, key comorbidities, admitted with …, day X
G: course so far in 2–3 lines
N: today’s events, results, consults
O: vitals, O₂, GCS, lines, feeds, mobility, prophylaxis
U: if … → …
T: 1. … 2. … 3. … (time, who to call)

One order for the note and the call. One line each.

• S · Sick or DNR: sick, watcher or stable; DNR or ceiling of care.
• I · Identifying data: age, sex, main comorbidities, admission reason, day of stay.
• G · General course: the story so far in two or three lines.
• N · New events: today’s results, consults, procedures, new drugs.
• O · Overall status: vitals, oxygen, GCS, lines, feeding, mobility, prophylaxis.
• U · Upcoming possibilities: what could go wrong tonight and what to do, as “if X, then Y”, with the reason.
• T · Tasks to complete: numbered, with times, who to call, and why.
• ? · Questions: the handover ends when the receiver has none.

I-PASS is the same content in a different order: illness severity, patient summary, action list, situation awareness and contingency, synthesis by the receiver. Use the one your unit uses.

Verbal handover follows the written note, in the same order, with the loop closed on every sick patient.

• Sender says it: one patient at a time, sickest first.
• Receiver acknowledges and repeats the key points: the contingency plan and the tasks, in their own words.
• Sender confirms or corrects.
• Any doubt about a number, a drug or a plan: ask now.

80-year-old woman, ward bed 30

• Train: know SIGNOUT, use it every time.
• Communicate: close the loop, repeat the plan back.
• Document: write it down, every time.
• Support: speak up, ask, back the person asking.

Based on a teaching session by Dr Mohamed A. Khafajy, KBIM, MRCP (UK). Frameworks: SIGNOUT (Horwitz et al., J Gen Intern Med 2007), TeamSTEPPS (AHRQ), I-PASS (Starmer et al., N Engl J Med 2014). Adverse-event figures: Canadian Adverse Events Study (Baker et al., CMAJ 2004).