• Led by Plymouth Hospitals NHS Trust with technical support from the University of Warwick.
  • The project ran from October 2008 until the end of 2013.
  • The project aimed to improve the handover systems within neurology and A&E departments to ensure correct and timely information was being shared about patients.
  • The team used various techniques to analyse and diagnose issues with the handover process, and a systems approach to help them redesign it.

The Plymouth Hospitals NHS Trust team wanted to improve handover systems in the neurology and A&E departments. Existing systems were unreliable, and core information about patients was not being passed between clinicians.

Unstructured handovers were leading to delays in decision-making, referrals and treatment.

With technical support from the University of Warwick, the team analysed and diagnosed issues, using techniques such as observing and process mapping systems, in-depth interviews and case studies.

Having defined a framework and core data set, the team created a new handover support tool.

The reliability of handovers – defined as core information being passed on – increased from 35% in June 2009, to more than 80% in September 2010.

Learning points from phase one

  • Explicit standards for clinical processes are needed so teams can develop shared understanding and measure success.
  • A proactive and explicit focus on improving safety is new and gains instant buy-in from clinicians.
  • Simple interventions can have a really big impact. However, just because an intervention is simple, does not mean it will be easy to implement.
  • Regular feedback to clinical teams about compliance against agreed standards and progress of the project increased their active participation.
  • Clinical autonomy can be a barrier to standardisation.
  • Communication is key, but finding time to meet, and ways to communicate with a constantly changing staff team was challenging.
  • Reductions in harm are difficult to measure and attribute to a particular intervention, meaning it can be difficult to justify this work in such a financially pressured climate.

Further reading

Research report

Safer Clinical Systems: Evaluation findings

December 2014

Lessons from the second phase of the Safer Clinical Systems programme.

About this programme


Safer Clinical Systems

A programme that ran in two phases from 2008 to 2013. It helped health care teams to proactively...

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