Paperless handover: are we ready?

To cite: Vidyarthi AR, Coffey M. BMJ Qual Saf Published Online First: [please include Day Month Year] doi:10.1136/bmjqs-2015005027 Scribbling patient information into the margins of pieces of paper during handover is a time-honoured tradition. House staff carefully guard these lists in pockets of white coats, on clipboards, or tucked into shoulder bags. They pull them out once the beeper goes off or mobile phone rings, and peer at the trusted information on the crumpled paper to guide their decision-making. ‘Patient So-and-So has a fever’, a nurse pages to inform the resident on-call, ‘Can we give something for the fever? Do you want any blood work?’ Other patients have confusion, pain or changes in their urine output. House staff record these events in check boxes, lines and circles, and read this back through bleary eyes to the incoming morning team. The scene describes a common experience for house staff using handover documents. Given the non-standardised formats and often idiosyncratic forms of documentation, it has come as no surprise that handover, (also known as handoff, sign-out, passoff or transfer of accountability) represents a common source of communication failures. As such, regulating bodies now mandate using structured handover processes and the teaching of handover competencies. 3 Over the past decade, a substantial body of research has informed our understanding of handover processes and quality, and a recent focused effort to improve handovers produced significant reductions in preventable patient harm. Notwithstanding these recommendations, the ritual of printing the handover document persists. In an analysis of the use of the printed handover document at a major academic medical centre, Rosenbluth et al examined its ‘half-life’, defined as the time at which half of the patients on the list would be expected to have inaccurate information present. They found that the half-life is remarkably short: only 3 h during the day and 6 h overnight. Their approach is novel and accessible, as they applied a familiar concept (‘half-life’) to a new element of patient care. Their message is clear: in today’s world of advanced information technology (IT), the printed handover document has lost its utility. But beneath this simple clarity lies substantial complexity, necessitating deeper consideration of current handover processes, the realities of today’s hospitalbased care delivery and a vision of a way forward. The handover document has evolved over time. Once taking the form of dozens of index cards hole-punched on a metal ring, it progressed to a manually updated simple stand-alone document on a shared drive. Today, many hospitals use electronic templates fully integrated into the electronic health record (EHR). Many of these electronic handover documents auto-import information and are available at all computer work-stations. This electronic handover progress has improved rounding efficiency and—in some institutions, at least—probably reduced medical errors. However, despite these advances and the explosion in clinical computing and handheld device usage, the practice of printing the handover document remains. Rosenbluth et al reveal the challenges posed when relying on the static information on the printed handover document. These are germane, but in order to understand the reliance on paper, we need to fully appreciate the purposes of the document. Originally, the handover document was described as a place for key information required for patient care during periods of cross-coverage, but its purpose has changed over time. At its most basic, the handover document is a map, displaying who our patients are and where they can be found. It is also a work-flow manager, where key tasks are written and crossed off continuously throughout the day and night. In many situations, the handover document is considered the most succinct place to locate patient information. In an era of copy and paste, progress notes can become long, complicated and plagued by stale EDITORIAL