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 difficulties and delays experienced by health care professionals. Handover of patient care has been highlighted as a high risk transaction by organisations including the National Patient Safety Agency (NPSA)i, the World Health Organisation (WHO) ii and the Australian Council for Safety and Quality in Health Careiii. The WHO emphasises that “gaps in communication can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm to the patient”.

The Clinical Safety Team of the Department of Health Informatics Division (DHID) which was previously part of NHS Connecting for Health (NHS CFH), has developed key guiding principles and related data items to be used for all types of clinical handover. The guiding principles and related data items are the product of evidence from the NPSA, the WHO and other international bodies and research NHS CFH commissioned from the Centre for Health Care Informatics Design at City Universityiv. They take the form of a combination of three key guiding principles and eight related data items. The data items are about accurate patient identification, coupled with questions (for which guidance will be provided) which will give information that must be included in transfer of information at handover. These guiding principles and the related data items are the subject of this consultation.

Explanation of Guiding Principles

The guiding principles for safer handover set the context for the use of the related data items.

There are three key guiding principles:

 the data items constitute a core set of issues which must be used in any and every clinical handover;

 the core set of issues is necessary, but not sufficient for any and every clinical handover – each health care setting will have its own, 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 Data Set Change Notices (DSCNs) 14/20091 and 18/20092.

1 This standard specifies the risk management processes required to minimise risks to patient safety in respect to the manufacture of health software products either as new systems or as changes to existing systems.

2 This standard specifies the risk management processes required to minimise risks to patient safety in respect to the deployment and use of software products either as new systems within a health organisation or as changes to an existing systems environment.

1 Academy of Medical Royal Colleges (AoMRC) standards for medical records The AoMRC 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 (www.rcplondon.ac.uk/resources/clinician%E2%80%99s-guide- record-standards-%E2%80%93-part-2-standards-structure-and-content-medical-record).

New core clinical headings for electronic record systems, conforming to the guiding principles, will shortly be published. They will support the handover process and provide a record of what was communicated at handover. Many healthcare settings will have discipline or setting specific essential additional data items to be transferred in the handover. The core content is designed to be supplemented with those data items, as appropriate to each care setting.

Why the Health Informatics Unit (HIU) of the Royal College of Physicians is conducting the consultation on the guiding principles and related data items The DHID Clinical Safety Team has been working with the HIU on the guiding principles and related data items because of the close links between them and the AoMRC national standard headings. Because the HIU led the development of the AoMRC standards, it has working relationships with the professional organisation of all the clinical disciplines. For this reason the HIU agreed to carry out the multi-professional consultation on the guiding principles and related data items with those professional organisations.

The Data Items which Relate to the Guiding Principles All clinical handovers of patient care should include records that travel with the patient and contain the following data items which relate to the guiding principles:

 Name ( ‘last name’ and ‘first name’ as endorsed by the ISB standard 04/2009 )

 Date of Birth (DOB)

 NHS Number

 What is wrong with this patient? e.g. Active Clinical Problems

 What has been done? E.g. Relevant Investigations & Treatments to date

 What needs to be done? E.g. Action plan – including when and by whom.

 Anything else I should know? / Alerts e.g. risks, allergies, statuses, disability etc.

 Responsible consultant/team/clinician e.g. GP making the handover

Proposed additional items

 Responsible consultant/team/clinician e.g. GP to whom the handover is being made

2  Guidance on a number to use when the NHS Number is not available – e.g. person becomes unconscious in the street v

 Medications – current

COT response 15 May 2012 1. Do you agree with the general approach of using guiding principles and related data items as set out in the consultation paper? YES

2. Do you agree with the following guiding principles?

 The data items constitute a core set of issues information which must be used in any and every clinical handover

 the core set of issues information is necessary, but not sufficient for any and every clinical handover – each health care setting will have its own, 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 Data Set Change Notices (DSCNs) 14/2009 and 18/2009 YES

3. Do you agree with the following related data items?

 Name ( ‘last name’ and ‘first name’ as endorsed by the ISB standard 04/2009 )

 Date of Birth (DOB)

 NHS Number

 What is wrong with the patient e.g. Active Clinical Problems

 What has been done. E.g. Relevant Investigations & Treatments to date

 What needs to be done. E.g. Action plan – including when and by whom.

 Anything else that should be known / Alerts e.g. risks, allergies, statuses, disability etc.

 Responsible consultant/team/clinician e.g. GP making the handover YES

4. Do you agree with all of the three suggested additional data items?

 Responsible consultant/team/clinician e.g. GP to whom the handover is being made

 Guidance on a number to use when the NHS Number is not available – e.g. person becomes unconscious in the street

 Medications – current YES

3 5. Are there any other data items you think should be included in the guiding principles for all handovers? YES

 Next of kin, and contact number

 Other services currently involved, e.g. social services, mental health, probation, drug and alcohol.

Chris Austin

Research and development officer

College of Occupational Therapists

4 i Safe handover: safe patients. Guidance on clinical handover for clinicians and managers (2004). London: NPSA,BMA and Modernisation Agency ii Communication During Patient Hand-Overs WHO - Patient Safety Solutions, volume 1, solution 3, May 2007 iii OSSIE Guide to Clinical Handover Improvement. Australian Commission on Safety and Quality in Health care. March 2009 iv NHS CFH Safer Handover Project: ER-08-0300 - Final Report on Safer Handover – Centre for Health Care Informatics Design, City University, London. July 2009 v Guidance from the NPSA says that where the NHS Number is not available, a hospital number or emergency numbering should be used until the NHS Number is available.