New guidance is needed on nursing handovers within hospital wards to ensure that staff have access to critical patient information, according to a new report from the Healthcare Safety Investigation Branch (HSIB).
Between April and November 2022 the HSIB carried out an investigation looking into how critical patient information is shared on hospital wards.
“There is a there is a lack of national guidance on nursing handovers and how exactly they should be done”
Lisa Elliott
The investigation was carried out following a case of mistaken identity where a patient was given inappropriate care because he was misidentified.
In this case, a 79-year-old man on an acute inpatient ward had a cardiac arrest, but was not given CPR because he had been misidentified.
The patient was mistakenly identified as the man in the next bed who had the same first name and who had a recommendation to not receive CPR.
The mistake was recognised around 10 minutes later by a nurse who was on a break and who had been previously caring for the patient. The patient was then given CPR, but it was unsuccessful.
Based on an investigation of this event, and a wider investigation carried out in hospitals across England, the HSIB found that clinical staff are not always able to access accurate critical patient information at hospital bedsides to support decision making in emergencies.
The investigation identified a number of obstacles in the way of staff always being able to access accurate information on patient identity and CPR recommendations.
These included faults in the ward handover process which meant that the nurse who attended the patient did not have critical information about him.
The investigators found that attendance at handovers varied with staff coming and going, there were regular interruptions and distractions, and handovers were commonly undertaken in corridors by whiteboards.
They also found that paper handover sheets were relied on, instead of electronic patient records, and that the content of the handover often varied depending on what was recorded on the handover sheets.
The handover sheets were read through line by line, but staff did not receive a handover for every patient they were expected to look after during their shift, the investigators added in their report.
“National organisations should be ensuring the accessibility and visibility of information”
Nick Woodier
Because they were unable to find any national guidance for nursing handovers similar to the guidance available for ward rounds, the investigators have recommended that the Royal College of Nursing develop guidance for ward-based nursing handovers, taking into consideration how they are organised, their content, the environment in which they take place and the technology needed to support them.
Lisa Elliott
Responding to this recommendation, the RCN’s UK deputy director of nursing: workforce, professional practice and quality, Lisa Elliott, said: “Nursing is the backbone of the NHS and safe care relies on a smooth handover from one nursing shift to the next in any setting.
“As this report highlights, there is a there is a lack of national guidance on nursing handovers and how exactly they should be done, and we are considering how the HSIB’s recommendation relation to this can be achieved.”
She added: “As the report says, there are a wide range of factors that need to be considered including digital technology, the environment and the amount of time required for an effective handover.”
Another obstacle to staff accessing critical patient information identified by the inquiry was poor access to digital systems.
This meant that staff frequently did not have access to electronic patient records and instead relied on less reliable paper-based systems.
“Providing patients’ names at their bedsides so they can be correctly identified is essential for safe care”
Nicola Byrne
A lack of easily accessible critical patient information at the hospital bedside was also identified.
Concerns about confidentiality frequently meant that critical patient information, including the patient’s full name, were not displayed at their bedside, leading to potential mix-ups such as that which occurred in the reference case.
The investigation has recommended that NHS England provide guidance on ensuring staff access to critical information, including CPR status, on the electronic patient record, and that steps should be taken to ensure that patient information should be consistently visible at the hospital bedside.
National Investigator for the HSIB Nick Woodier said that the reference case was a “distressing reminder of what can happen when treatment is delayed because staff are not able to easily see the critical information they need in an urgent situation”.
He added: “National organisations should be ensuring the accessibility and visibility of information, so that staff can provide the best levels of care to patients at the bedside, many of whom could be in a critical condition and may need life-saving treatment.”
National data guardian for health and social care Dr Nicola Byrne said: “Providing patients’ names at their bedsides so they can be correctly identified is essential for safe care.”
She added that the Caldicott principles, which give guidance on confidentiality, include principle seven, which advises that “the duty to share information for individual care is as important as the duty to protect patient confidentiality”.
