Communication: Is There a Standard Handover Technique to Transfer Patient Care?

Abstract

Effective communication is integral to patient safety, especially during high-risk periods where patients are transitioning to different care areas or to different providers. However, communication failures continue to occur; The Joint Commission (TJC) reports that the number one cause of anesthesia-related sentinel events is breakdown in communication. 1 The operating room (OR), the postanesthesia care unit (PACU), and the intensive care unit (ICU) are especially vulnerable to communication failures between providers; inadequate communication in the PACU has been shown to affect mortality and morbidity. 2,3 A review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS) indicated failure in communication as the second most common contributing factor to adverse events in recovery units. 4 Indeed, observational studies have shown a direct correlation between poor handover and patient harm. 5 Therefore, the handover process is critical to the safe care of the surgical patient. The handover is a transfer of not only information but also of professional responsibilities across teams. 6 Ideally, a handover report is attended by surgical and anesthesia staff, a nurse, and a PACU or an ICU clinician, and relays information on the patient's history, intraoperative events, and postoperative care plan. According to the American Society of Anesthesiologists, standard of care requires the presence of intraoperative anesthesia staff for monitoring during transport and verbal report. 7 However, beyond this, there is a lack of consistent guidelines; reports are vulnerable to omission of pertinent information. 8 A complete omission of information occurred in 57% of surgical malpractice claims 9 and has

Factors associated with nurses’ perceptions, their communication skills and the quality of clinical handover in the Hong Kong context

“…Furthermore, some researchers have reported possible limitations of standardised handover tools [ 25 – 27 ], in which one example being the use of a standardised checklist did not necessarily lead to a high level of consistency during handovers even for experienced nurses [ 20 ]. Additionally, several studies about the efficacy of the implementation of ISBAR on nurses’ handover performance also showed that despite a higher-frequency query of ambiguous information, errors still occurred during handover, which in turn led to a lower self-perceived quality of handover practices [ 28 , 29 ].…”

Comunicação e segurança do paciente em Unidade de Terapia Intensiva: perspectivas da equipe multiprofissional de saúde

“…A simulação pode ajudar os membros da equipe a definir quem precisa estar presente na transferência. Equipe multiprofissionais em saúde, incluindo enfermeiras, anestesistas, fisioterapeutas e outros, podem se beneficiar da configuração de simulação para ganhar familiaridade uns com os outros e com o papel particular de cada área durante o processo de transferência (Methangkool et al, 2019).…”

“…Além disso, o processo de implementação do processo de transferência padronizado deve incluir medidas para garantir a sustentabilidade da iniciativa. A comunicação eficaz é crítica para transferir o atendimento ao paciente de uma forma que reduza os danos (Methangkool et al, 2019).…”

Transition of care: Nurses' perception in an emergency service

“…A transferência de informação entre equipas de enfermagem no fim do turno é uma prática diária dos enfermeiros. Visa assegurar a continuidade de cuidados e promover a segurança dos mesmos (Direção Geral da Saúde, 2017), representado, por isso, um momento relevante da prática profissional, mas simultaneamente complexo, que acarreta em si um potencial contributo para a ocorrência de erros na tomada de decisão, resultantes de omissões ou deturpação da informação (Desmedt et al, 2021;Methangkool et al, 2019).…”