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Emergency Care Handover

Clinical Handover in the Emergency Care Pathway and the Potential for Harm of Clinical Handover Failures (ECHO)

funded by NIHR HS&DR (2011 - 2012)

Please see also the NIHR HS&DR programme website for this project.


The project addresses the following research questions:

  • What is the potential for harm of clinical handover failures along the Emergency Care pathway?
  • What are common organisational deficiencies that affect clinical handover in the Emergency Care pathway and what impact does the organisational model of care delivery have?

We have chosen five organisations with different characteristics to explore handovers within the Emergency Care
pathway, i.e. with the explicit consideration of interfaces between organisations or departments. The research objectives will
be achieved through the following work streams:

  • WP1: Potential for harm of clinical handover failures along the Emergency Care pathway
    We will systematically describe the handovers in terms of their purpose and how they take place, and assess the communication patterns during handover (including the frequency with which information is handed over). We will then assess the potential impact of handover failures on the pathway and on patient outcomes using Failure Mode & Effects Analysis (FMEA).
  • WP2: Common organisational deficiencies and the impact of organisational models of care delivery
    In the second work stream we will conduct interviews with staff in order to qualitatively explore the organisational factors and deficiencies that impact the quality of handover. We will also perform a comparative analysis of the impact on handover of the different ways that Emergency Care is organised in the three sites.
  • WP3: Recommendations for improving the reliability & quality of handover
    A workshop on improving the quality of handover will be held on July 16th at the College of Emergency Medicine in London. The workshop aims to elicit a broader view on potential interventions to improve the quality of handover in a sustainable way. This final work package will document in a report the findings and recommendations of the study and the workshop with the support from clinicians and health finance experts.

Project team

Mark-Alexander Sujan (PI)

Matthew Cooke

Peter Spurgeon

Matthew Inada-Kim (Royal Hampshire County Hospital)

Steve Cross (United Lincolnshire Hospitals)

Larry Fitton (Oxford Radcliffe Hospitals)


1. Sujan MA, Spurgeon P, Inada-Kim M et al. Clinical Handover within the Emergency Care Pathway and the Potential Risks of Clinical Handover Failure (ECHO): Primary Research. Health Services and Delivery Research 2014:2(5)

The final project report has been published online and open access in the NIHR Journals Library. The findings of the research suggest that handover should be understood as a sociotechnical activity embedded in clinical and organisational practice. Capacity, patient flow and national targets, and the quality of handover are intricately related, and should be addressed together. Improvement efforts should focus on providing practitioners with flexibility to make trade-offs in order to resolve tensions inherent in handover. Collaborative holistic system analysis and greater cultural awareness and collaboration across organisations should be pursued.

2. Sujan MA, Chessum P, Rudd M et al. Managing competing organizational priorities in clinical handover across organizational boundaries. Journal of Health Services Research and Policy 2015;20(1S):17-25 (Open Access)

This paper interprets the interview data collected during the second phase of the project. The management of patient flow and the fulfilment of time-related performance targets can create conflicting priorities for practitioners during handover. Practitioners involved in handover manage such competing organizational priorities through additional coordination effort and dynamic trade-offs. Practitioners perceive greater collaboration across departments and organizations, and mutual awareness of each other’s goals and constraints as possible ways towards more sustainable improvement.

3. Sujan M, Spurgeon P, Cooke M. The role of dynamic trade-offs in creating safety - A qualitative study of handover across care boundaries in emergency care. Reliability Engineering and System Safety 2015; doi:10.1016/j.ress.2015.03.006 (PDF Document)

This paper was published as part of a special issue on Resilience Engineering. The paper aims to demonstrate how the study of everyday clinical work can contribute novel insights into the vulnerabilities of handover across care boundaries in emergency care. The paper argues that performance variability is an essential component in the delivery of safe care, as practitioners translate tensions they encounter in their everyday work into safe practices through dynamic trade-offs based on their experience and the requirements of the specific situation. The findings may shed new light on the vulnerabilities of the handover process, and they might help explain why improvements to handover have remained largely elusive and what type of future recommendations may be appropriate for improving patient safety.

4. Sujan MA, Chessum P, Rudd M et al. Emergency Care Handover (ECHO Study) across care boundaries: the need for joint decision making and consideration of psychosocial history. Emerg Med J Published Online First: 11 September 2013 doi:10.1136/emermed-2013-202977 (full paper available free of charge through Open Access from EMJ)

This paper explores both what is communicated (content) and how this is communicated (verbal behaviours) during different types of handover conversations across care boundaries in emergency care. Inter-organisational (ambulance service to ED in “Resuscitation” and “Majors” areas) and inter-departmental handover conversations (referrals to acute medicine) were audio recorded. Handover conversations were segmented into utterances. Frequency counts for content and language forms were derived for each type of handover using Discourse Analysis. Verbal behaviours were identified using Conversation Analysis. Handover may entail both descriptive talk aimed at information transfer and collaborative talk aimed at joint decision-making. Standardisation of handover needs to accommodate collaborative aspects, and should incorporate communication of information relevant to the patient’s social and psychological needs to establish appropriate care arrangements at the earliest opportunity.

5. Sujan M. Care handovers are letting down patients. Health Service Journal, 23 September 2013 (available free here from HSJ)

This short opinion piece argues that handover practices should pay more attention to the social and psychological needs of elderly patients in order to facilitate integrated care approaches that aim to improve the quality of care delivered to an increasingly elderly population.

6. Sujan M, Spurgeon P, Cooke M. Translating Tensions into Safe Practices Through Dynamic Trade-offs: The Secret Second Handover. In Resilient Health Care: Resilience of Everyday Clinical Work, Editors: Robert Wears, Erik Hollnagel, Jeffrey Braithwaite, Ashgate, 2015 (PDF Document) 

This book chapter describes an informal practice (second handover), and analyses how practitioners provide resilience to the system through such local performance adaptations.

7. Sujan M., Felici M. Combining Failure Mode and Functional Resonance Analyses in Healthcare Settings. In Ortmeier F., Daniel P. SAFECOMP 2012, LNCS 7612, pp. 364-375, Springer Verlag (paper (PDF Document) / presentation (PDF Document))

The paper describes experiences with the application of Failure Mode and Effects Analysis (FMEA) for the safety analysis of handover in emergency care, and some of the limitations encountered. The paper then presents early results of the application of Functional Resonance Analysis Method (FRAM) as a complementary approach that focuses on variability rather than on failure modes.

8. Sujan M., Spurgeon P. Safety of Patient Handover in Emergency Care - Results of a Qualitative Study. In Proceedings of the Annual European Safety & Reliability Conference (ESREL) 2013, Amsterdam (paper (PDF Document))

The paper presents the results of the thematic analysis of 39 semi-structured interviews with staff from the five participating study organisations. The analysis identified two main themes: (1) tensions in the activity of handover that require dynamic trade-offs, and (2) the influence of the management of patient flows on the quality of handover.

This project was funded by the National Institute for Health Research Health Services and Delivery Research (NIHR HS&DR) programme (project number 10/1007/26). Visit the HS&DR website for more information.
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR programme, NIHR, NHS or the Department of Health.