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Clinical Handover
Standard 6: Clinical Handover
The Victorian Department of Health is making this document freely available on the internet for health
services to use and adapt to meet the National Safety and Quality Health Service Standards of the
Australian Commission on Safety and Quality in Health Care. Each health service is responsible for all
decisions on how to use this document at its health service and for any changes to the document. Health
services need to review this document with respect to the local regulatory framework, processes and
training requirements
The author disclaims any warranties, whether expressed or implied, including any warranty as to the
quality, accuracy, or suitability of this information for any particular purpose. The author and reviewers
cannot be held responsible for the continued currency of the information, for any errors or omissions, and
for any consequences arising there from.
Published by Sector Performance, Quality and Rural Health, Victorian Government, Department of Health
June 2014
Clinical Handover
1
Acknowledgements
The Department of Health Victoria acknowledges the contribution of medical and health specialists,
Victorian health services, and members of the National Safety and Quality Health Service Standards:
Educational Resources Project project team, Steering Group and Advisory Committee.
The Educational Resources Project Steering Group members comprised:
 Associate Professor Leanne Boyd, Steering Group Chair; Director of Education, Cabrini Education
and Research Precinct, Cabrini Health
 Ms Madeleine Cosgrave, Project Manager
 Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre
 Mr. David Brown, Consumer representative
 Dr Jason Goh, Medical Administration Registrar - Cabrini Health
 Mr Matthew Johnson, Simulation Manager, Cabrini Education and Research Precinct, Cabrini
Health
 Ms Tanya Warren, Educator, Cabrini Education and Research Precinct, Cabrini Health
 Ms Marg Way, Director, Clinical Governance, Alfred Health
 Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria
The Educational Resources Project Advisory Committee members comprised:
 Associate Professor Leanne Boyd, Advisory Committee Chair; Director of Education, Cabrini
Education and Research Precinct, Cabrini Health
 Ms Madeleine Cosgrave, Project Manager
 Ms Margaret Banks, Senior Program Director, Australian Commission on Safety and Quality in
Health Care
 Ms Marrianne Beaty, Oral Health National Standards Advisor, Dental Health Services Victoria)
 Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre
 Mr David Brown, Consumer representative
 Dr Jason Goh, Medical Administration Registrar, Cabrini Health
 Ms Catherine Harmer, Manager, Consumer Partnerships and Quality Standards, Department of
Health, Victoria
 Ms Cindy Hawkins, Director, Monash Innovation and Quality, Monash Health
 Ms Karen James, Quality and Safety Manager, Hepburn Health Service
 Mr Matthew Johnson, Simulation Manager, Cabrini Health
 Ms Annette Penney, Director ,Quality and Risk, Goulburn Valley Health
 Ms Gayle Stone, Project Officer, Quality Programs, Commission for Hospital Improvement,
Department of Health Victoria
 Ms Deb Sudano, Senior Policy Officer, Quality and Safety, Department of Health Victoria
 Ms Tanya Warren, Educator, Cabrini Health
 Ms Marg Way, Director, Clinical Governance, Alfred Health
 Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria
Clinical Handover
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Contents
Clinical Handover
4
Introduction
4
Learning outcomes
4
National Standards
4
Aim of Standard 6
4
Policies and procedures
4
Background
5
Principles of clinical handover
5
Structure of clinical handover
6
Your role in clinical handover
7
Engaging with patients and carers
8
Audit and evaluation
8
Reporting adverse events
9
Summary
10
Test Yourself
11
Answers
12
References
13
Appendix 1: Examples of structured clinical handover tools
14
iSoBAR
14
ISBAR
16
SBAR
17
SHARED
18
Hand me an ISOBAR Handover Tool
19
Clinical Handover
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Clinical Handover
Introduction
Aim of Standard 6
This module relates to the National Safety and
Quality Health Service (NSQHS) Standard 6: Clinical
Handover.
The intention of Standard 6: Clinical Handover is to
ensure that a timely, relevant and structured clinical
handover occurs that is appropriate to the clinical
setting and context of the handover.
Standard 6 also relates to Standard 1: Governance
for Safety and Quality in Health Service
Organisations and Standard 2: Partnering with
Consumers. The principles in these Standards are
fundamental to all Standards and provide a
framework for their implementation.
ACSQHC, 2012
Criteria to achieve Standard 6:
Governance and leadership for effective clinical
handover
Learning outcomes
Health service organisations implement effective
clinical handover systems.
On completion of this module, clinicians will be able
to:
Clinical handover processes
1. Discuss the importance of timely, relevant
and structured clinical handover.
2. Discuss the clinical handover process
including the use of a structured handover
tool.
3. Describe your responsibilities in clinical
handover.
4. Describe the process for engaging patients
and carers in clinical handover.
National Standards
The Australian Commission on Safety and Quality in
Health Care (ACSQHC) developed the 10 NSQHS
Standards to reduce the risk of patient harm and
improve the quality of health service provision in
Australia. The Standards focus on governance,
consumer involvement and clinically related areas
and provide a nationally consistent statement of the
level of care consumers should be able to expect
from health services.
Clinical Handover
Health service organisations have documented and
structured clinical handover processes in place.
Patient and carer involvement in clinical handover
Health service organisations establish mechanisms to
include patients and carers in the clinical handover
processes.
Table 1: Criteria to meet Standard 6 (ACSQHC), 2012
Policies and procedures
There are numerous policies, procedures and
resources within health care services to assist you
with clinical handover. It is important to access,
read and adhere to systems, policies and procedures
within your organisation.
4
Background
Clinical handover is practised every day, in a
multitude of ways, in all health care settings.
Poor or absent clinical handover, or a failure to
transfer information, responsibility and
accountability, can have extremely serious
consequences for patients.
It can result in:

delays in diagnosis, treatment and care

tests being missed or duplicated

incorrect treatment or medication
ACSQHC, 2011
Current handover practices are highly variable and
unreliable across all disciplines. This can lead to
discrepancies in the content and accuracy of
information provided.
Other barriers to communication within health care
organisations include hierarchy, gender, ethnic
background and differences in communication
styles. These inconsistencies in communication
cause considerable risk to patient safety and care.
Standardisation of handover content and processes
improves patient safety by ensuring consistency in
the exchange of critical information.
ACSQHC, 2010
Principles of clinical handover
The aim of clinical handover is to ensure the
accurate and timely transfer of information,
responsibility and accountability. The key principles
include:
It is important that clinicians listen to patients and
carers to gain an understanding of this information.
It is also essential that patients and carers
understand current progress, treatment options and
the plan of care.
The risk of a patient experiencing an adverse event is
reduced by actively involving them in their own care.
ACSQHC, 2012
HANDOVER REQUIRES PREPARATION
Handover requires preparation prior to handover
time.
Handover should occur at an allocated time and
venue which enables all necessary staff to attend.
Documents and progress notes should be updated
and available at handover time. It is recommended
that verbal handover is supported by documentation
such as handover sheets.
Staffing levels and allocations should ensure that
patient care is attended to while handover is
occurring.
ACSQHC, 2010
HANDOVER NEEDS TO BE WELL ORGANISED
Handover should be led by a designated staff
member who is responsible for ensuring the
exchange of all relevant communication in a timely
manner.
Punctuality is important as handover is:

crucial to patient safety

paid and protected time for employees
ACSQHC, 2010
PATIENT AND CARER INVOLVEMENT
Where possible, clinical handover should actively
involve the patient and carer as well as clinicians.
Patients and carers can provide information that is
not necessarily available to clinicians.
Clinical Handover
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HANDOVER SHOULD PROVIDE ENVIRONMENTAL
AWARENESS
The incoming team need to be informed of any
environmental issues (particularly occupational
health and safety issues), which might impact on the
shift.
Structure of clinical handover
Handover should always include notification of:
Handover requires the transfer of standard
information between:
 patients who may require significant levels
of care or immediate attention
All clinical handover processes need to be structured
and documented. This ensures that all participants
know the purpose of the handover, the required
information and documentation they need to share.

clinicians within a discipline
 high acuity patients

from one discipline to another
 patients who are deteriorating or at risk of
deterioration

wards or departments within a health
service
 patients who require extra safety measures
e.g. infective or bariatric patients

health services
 potential or scheduled patient transfer or
discharge
 staffing numbers and arrangements e.g.
allocations and activities
ACSQHC, 2010
HANDOVER MUST INCLUDE TRANSFER OF
ACCOUNTABILITY AND RESPONSIBILITY FOR
PATIENT CARE
Patient handover must ensure the transfer of
responsibility and accountability between clinicians
and health services.
A standard structure and content for clinical
handover assists in accurately communicating critical
information between clinicians.
ACSQHC, 2010
Handover should occur:

at change of shift

from one ward to another ward or
department

at patient transfer to another facility

on patient discharge

when a patient’s condition warrants it
CLINICAL HANDOVER TOOLS
A number of handover tools have been developed to
assist health care professionals to conduct clinical
handovers in a structured and comprehensive way.
Structured handover tools are used to ensure that
staff are sharing relevant, concise and focused
information.
They also:

encourage patient assessment

facilitate effective communication

reduce the need for repetition

save time for clinicians
NHS, 2013
Clinical Handover
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These tools are checklists which can assist to
standardise handover. Acronyms can be used to
assist clinicians to remember the information
required for handover. Some examples can be
found in Appendix 1.
Minimum datasets are required for all forms of
handover. This is the minimum information and
content required for a particular type of handover.
ACSQHC, 2010
HANDOVER METHODS
Face to face handover is recommended wherever
possible as it allows interaction and clarification of
information. This should be guided by the agreed
patient handover tool and supported by a summary
of updated patient information.
Using only verbal handover is high risk because it
relies heavily on memory. The addition of
supportive tools and documentation can:

minimise the risk of omitting information

improve retention of information

minimise repetition

reduce the length of handover
If the patient is to be escorted to a department by a
non-clinical staff member a clinician must provide a
verbal handover to a nominated member of the
receiving department. This staff member will then
assume responsibility and accountability for the
patient.
GIVING HANDOVER
If you are giving handover ensure you have:
Communicated with the patient and carer
Discuss details of planned transfers and discharges
with the patient and carer.
Communicated with the receiving clinician
It is important that the receiving clinician and
department are prepared to accept the patient and
are aware of the estimated time and details of
patient arrival.
Checked and assessed your patient
Confirm your patient’s identification details and
assess your patient to ensure they are stable and
prepared for handover, transfer or discharge.
Completed documentation
ACSQHC, 2010
It is important to ensure that the person receiving
handover has understood correctly.
A written handover is suitable for patients who are
stable, but the sending clinician should be available
to provide clarification of patient information if
required to do so by the receiving team.
Your role in clinical handover
All required documentation needs to be updated
and completed. This includes:

preparation of handover forms

updating progress notes

completing any transfer or discharge forms
including information regarding:
o treating doctor
o admission date and diagnosis
o key events during admission
There are some important points to consider when
giving or receiving handover.
o discharge summary
It is vital to maintain the confidentiality of patient
information and patient privacy at all times.
o referrals
o risks and prevention strategies
Ensure all necessary documentation is kept with the
patient.
Clinical Handover
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RECEIVING HANDOVER
If you are receiving handover, ensure you have:
You should consider the following when discussing
clinical handover with patients and carers:

patients and carers can provide information
that is not necessarily available to clinicians
as carers are more familiar with the patient
and may spend more time at the bedside.

ensuring patients and carers understand
current progress, treatment options and the
plan of care
You should be aware of the estimated time of
patient arrival and have the environment prepared
to receive the patient. Ensure you understand all
relevant patient details and clarify anything you are
unsure about.

explaining the need for clinical handover

explaining the patient and carers role in
clinical handover, and encouraging them to
raise questions and concerns with the health
care team
Checked and assessed your patient

offering information in languages other than
English and not assuming literacy

providing an opportunity for patients and
carers to ask questions and have them
answered
Communicated with the patient and carer
Introduce yourself to the patient and carer and
orientate them to the environment.
Communicated with the clinician providing
handover
On arrival, you should perform a baseline head-totoe assessment on the patient and document
findings in the progress notes.
Any areas of concern or points that require
clarification should be discussed with the clinician
providing handover before accepting responsibility
for the patient.
You should ensure that the patient and carer
understand the course of the care and have up to
date information about the discharge date and plan.
ACSQHC, 2012
Completed documentation
Ensure that all necessary documentation has arrived
with the patient. All documentation, including
medication and fluid charts, should be checked for
accuracy and completion.
Responsibility and accountability for the patient
must be accepted at the completion of clinical
handover.
Engaging with patients and carers
Patients and carers should be educated about the
need for clinical handover and their role in the
process.
This collaboration enables an opportunity for
patients, carers and clinicians to share information
which may impact on the effectiveness of treatment
and care and raise any issues of concern.
Clinical Handover
Audit and evaluation
You may be required to participate in audit activities
which could include examination of:

patient clinical records

handover documentation
You may be observed in clinical practice when
performing clinical handover.
The purpose of audit is to measure compliance with
policies and protocols and to monitor the frequency
and severity of adverse events in relation to clinical
handover. This information can be used to improve
practice.
8
Reporting adverse events
All adverse events relating to poor or absent clinical
handover should be reported to the nurse/midwife
in charge, the attending medical officer (if
necessary) and be documented in the clinical record.
They should also be reported on your organisation’s
risk or incident management system.
Patients and carers should be fully informed of any
adverse events and the organisation’s open
disclosure processes implemented.
Information trends can then be used to inform
quality improvement activities such as system,
policy, protocol and equipment improvements and
education and training activities.
ACSQHC, 2012
Clinical Handover
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Summary
Clinical handover is the focus of Standard 6 in the
National Safety and Quality Health Service
Standards.
The key messages are:
1.
Clinical handover is practised every day, in a
multitude of ways, in all health care settings.
2. Poor or absent clinical handover, or a failure
to transfer information, responsibility and
accountability, can have extremely serious
consequences for patients.
3. Current handover practices are highly
variable and unreliable across all disciplines.
This can lead to discrepancies in the content
and accuracy of information provided.
4.
The aim of clinical handover is to ensure the
accurate and timely transfer of information,
responsibility and accountability.
5.
Where possible, clinical handover should
actively involve the patient and carer as well
as clinicians. Patients and carers can provide
information that is not necessarily available
to clinicians.
9.
Face to face handover is recommended
wherever possible as it allows interaction
and clarification of information.
10. It is vital to maintain the confidentiality of
patient information and patient privacy at all
times.
11. Patients and carers should be educated
about the need for clinical handover and
their role in the process.
12. All adverse events relating to poor or absent
clinical handover should be reported in the
risk or incident management system.
6. The key principles include:

handover requires preparation

handover needs to be well organised

handover should provide
environmental awareness

handover must include transfer of
accountability and responsibility for
patient care
7.
Structured handover tools are used to
ensure that staff are sharing relevant,
concise and focused information.
8.
Minimum datasets are required for all forms
of handover. This is the minimum
information and content required for a
particular type of handover.
Clinical Handover
10
Test Yourself
Fill in the blanks
1. Standardisation of handover _____________ and processes improves patient safety by ensuring
_____________ in the exchange of critical information.
2. Where possible, clinical handover should __________ involve the patient and carer as well as
clinicians.
3. ______________ and carers can provide _______________ that is not necessarily available to
clinicians.
4. It is recommended that __________ handover is supported by ________________ such as handover
sheets.
5. Handover should always include notification of patients who may require significant levels of _______
or immediate _______________.
6. Patient handover must ensure the transfer of ________________ and ___________________
between clinicians and health services.
7. _________________ handover tools are used to ensure that staff are sharing ____________, concise
and focused information.
8. Minimum datasets are required for _____ forms of handover. This is the _______________
information and content required for a particular type of handover.
9. Face to face handover is recommended wherever possible as it allows ______________ and
_______________ of information.
10. A standard structure and content for clinical handover assists in _________________ communicating
____________ information between clinicians
Clinical Handover
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Answers
1. content, consistency
2. actively
3. patients, information
4. verbal, documentation
5. care, attention
6. responsibility, accountability
7. structured, relevant
8. all, minimum
9. interaction, clarification
10. accurately, critical
Clinical Handover
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References
Australian Commission on Safety and Quality in Health Care (2010). OSSIE Guide to Clinical Handover
Improvement. Sydney. ACSQHC, 2010.
Australian Commission on Safety and Quality in Health Care (2012). Safety and Quality Improvement Guide
Standard 6: Clinical Handover (October 2012). Sydney. ACSQHC, 2012. Sydney. Commonwealth of Australia
Australian Commission on Safety and Quality in Health Care (2013). Clinical Handover, Standard 6: Fact Sheet
(October 2012). Sydney. ACSQHC, 2012. Sydney. Commonwealth of Australia
NHS Institute for Innovation and Improvement, 2013. SBAR Overview. Accessed at
http://www.institute.nhs.uk/safer_care/safer_care/situation_background_assessment_recommendation.html
#why
The Victorian Quality Council: Safety and Quality in Health (2012). Guide to patient transfer: Principles and
minimum requirements for non-time critical inter-hospital patient transfer. Victorian Government Department
of Health, Melbourne, Victoria. Accessed at
http://docs.health.vic.gov.au/docs/doc/Guide-to-Patient-Transfer-Principles-and-Minimum-Requirements-fornon-time-critical-inter-hospital-patient-transfer-December-2012
Clinical Handover
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Appendix 1: Examples of structured clinical
handover tools
iSoBAR
iSoBAR was initially developed for use during inter-hospital transfer, specifically where handover occurred
over the phone. Please refer to Table 2 for details of the iSoBAR acronym. iSoBAR was trialled in Western
Australia and remains in use for many handover scenarios because it was found to be easy to adapt and
integrate into existing work processes (ACQSHC, 2010).
i
IDENTIFY
Introduce yourself and your patients
S
SITUATION
Describe the reason for handing over
o
OBSERVATIONS
Include vital signs and assessments
B
BACKGROUND
Pertinent patient information
A
AGREE A PLAN
Given the situation, what needs to happen
R
READBACK
Confirm shared understanding
Table 2: iSoBAR handover tool (Porteous, Stewart-Wynne, Connolly and Crommelin, 2009)
I = IDENTIFCATION OF PATIENT
This step should include positive confirmation of the patient’s identity using at least three identifiers: for
example patient name, date of birth and medical record number.
S = SITUATION AND STATUS
This step includes the patient’s current clinical status (e.g. stable, deteriorating, improving), advanced
directives and patient-centred care requirements including the prospect of discharge or transfer.
O = OBSERVATION
This step ensures the incoming team is informed of the latest observations of the patient and when they were
taken. It serves as a checking mechanism to identify deteriorating patients for emergency response assistance.
Unit members need to be aware of local emergency response call criteria and processes.
Why introduce ‘O’ for observation?
In some handover acronyms, observation is included under ‘S’ (Situation). However, handover research in
several Australian states showed that ‘old’ or inaccurate observations were frequently handed over. There are
numerous reported cases where assistance was not called for patients who suffered serious deterioration or
death. Observations that should have prompted a call for assistance were sometimes recorded over a long
period of hours, including across shift handover. The explicit introduction of ‘O’ is therefore designed to ensure
that if patients meet call criteria for an emergency response team or process that handover at least will trigger
that call.
B = BACKGROUND AND HISTORY
This step provides the incoming team with a summary of background; history (the presenting problem,
background problems and current issues); evaluation (physical examination findings, investigation findings and
current diagnosis); as well as management to date and whether it is working.
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A = ASSESSMENT AND ACTIONS
This step is to ensure that all tasks and abnormal or pending results are clearly communicated. Most
importantly, there must be an established and agreed management and escalation of care plan, which could
include:

a shared understanding of what conditions are being treated or, if the diagnosis is not known, clear
communication of this fact to everyone

tasks to be completed

abnormal or pending results (must include recommendations and the agreed plan and who to call if
there is a problem)

a plan for communication to the senior in charge

clear accountability for actions
R = RESPONSIBILITY AND RISK MANAGEMENT
Clinical handover must include the transfer of responsibility as staff are leaving the institution. This can only
be achieved through acceptance of tasks by the incoming team, which is best ensured by face-to-face
handover. Where risks are identified for a patient, clinical risk management strategies (such as for infectious
disease alerts or alerts for DVT prophylaxis) should be clearly communicated.
ACQSHC, 2010
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ISBAR
ISBAR was trialled for interhospital transfer within NSW. Health professionals reported the tool was simple,
memorable and portable (ACQSHC, 2010) and has since been implemented in a number of hospitals within
NSW. In Victoria, a partnership between the VMIA and Southern Health developed resources to assist in
implementing ISBAR in Health Services. These resources are available at: http://www.vmia.vic.gov.au/RiskManagement/Risk-partnership-programs/Projects/ISBAR.aspx
Figure 1: ISBAR handover tool (ACQSHC, 2010)
There is an ISBAR application available to download free from ITunes app store. The application provides
health professionals with handover prompts for a variety of clinical handovers including:

medical

surgical

mental health

obstetrics and gynaecology

paediatrics

deteriorating patient
The app facilitates the development of individual handover prompts for other specialties, consistent with the
flexible standardisation implementation methodology.
Clinical Handover
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SBAR
This handover tool has been used in many communication situations, including executive briefings and
incident reports and was trialled in SA, WA and Vic. The tool was utilised to facilitate shift to shift
handover and nurse to doctor communication. Results supported its utilisation with 80% of respondents
noting that handover had improved and reporting more confidence when communicating with doctors
(ACSQHC, 2010). SBAR reduces the incidence of missed communications that occur through the use of
assumptions, hints, vagueness or reticence they may be caused by the authority gradient.
1. It helps to prevent breakdowns in verbal and written communication, by creating a shared mental
model around all patient handovers and situations requiring escalation, or critical exchange of
information.
2. SBAR is an effective mechanism to level the traditional hierarchy between doctors and other care
givers by building a common language platform for communicating critical events, thereby
reducing barriers to communication between health care professionals.
3. As a memory prompt, it is easy to remember and encourages prior preparation for
communication.
4. Used during handover SBAR can reduce the time spent on this activity thereby releasing time for
clinical care (NHS Institute for Innovation and Improvement, 2013).
The mnemonic is detailed in Table 3.
S
Situation
What is the situation? (Chief complaint, current status)
B
Background
What is the clinical background? (Previous history)
A
Assessment
What is the problem? (Results of assessment, vital signs and symptoms)
R
Request/ Recommendation
What do I recommend/request to be done? (Suggested and anticipated changes, critical monitoring)
Table 3: SBAR handover tool (ACSQHC, 2010)
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SHARED
The SHARED handover tool was trialled in Queensland to address the communication issues associated
with the critical time around the following points of care within maternity services:

Referral from the midwife to the doctor when a change in the woman’s condition is diagnosed.

Referral from the doctor to the recovery nurse/midwife post Caesarean section.
The project found that the SHARED tool provided a standardised approach that defined the minimum
dataset. Improvements in accuracy and appropriateness of information were noted (ACSQHC, 2010).
Details of the tool can be found in Table 4.
S
Situation
Reason for admission/phone call/change in condition; diagnosis specific information
H
History
Medical/surgical/psychosocial/recent treatment/responses and events
A
Assessment
Results/blood tests/X-rays scans/observations/severity of condition
R
Risk
Allergies/infection control/literacy/cultural/drugs/skin integrity/mobility/falls
E
Expectation
Expected outcomes; plan of care; timeframes; discharge plan; escalation
D
Documentation
Progress notes; care path; relevant electronic health record/database
Table 4: Shared handover tool (ACSQHC, 2010)
Clinical Handover
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Hand me an ISOBAR Handover Tool
HAND ME AN ISOBAR
The major principles of clinical handover have been combined with the ISOBAR handover tool to form the
acronym “HAND ME AN ISOBAR”. This reflects what needs to occur and what information needs to be
exchanged during shift to shift nursing handovers.
Step 1: HAND
(prepare for handover)
H Hey, it’s handover time!
A Allocate staff for continuity of patient care
N Nominate participants, time and venue/s
D Document on written sheets and patient notes
Step 2: ME
(organise handover)
M Make sure all participants have arrived
Step 3: AN
(patient and safety focus)
A Alerts, attention and safety
Step 4: ISOBAR (provide
handover for individual
patients)
I Identification of patient
E Elect a leader
N Nothing about me, without me......INVOLVE THE PATIENT
S Situation and status
O Observations of patient (+/-need for emergency calls)
B Background and history
A Action, agreed plan and accountability
R Responsibility and risk management
Table 5: Hand Me an ISOBAR (ACSQHC, 2010)
Clinical Handover
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Clinical Handover
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