International Journal for Quality in Health Care Advance Access published August 10, 2016

International Journal for Quality in Health Care, 2016, 1–7

doi: 10.1093/intqhc/mzw082
Quality in Practice

Quality in Practice

Implementing electronic handover:

interventions to improve efficiency, safety
and sustainability
SHARIFAH MUNIRAH ALHAMID1, DESMOND XUE-YUAN LEE2,
HEI MAN WONG1, MATTHEW BINGFENG CHUAH1, YU JUN WONG1,
KAAVYA NARASIMHALU1, THUAN TONG TAN3, and SU YING LOW4
1
Internal Medicine Residency, Singapore Health Services, Singapore General Hospital, Outram Road, 169608,
Singapore, 2Clinical Services and Improvement, Division of Medicine, Singapore General Hospital, Outram Road,
169608, Singapore, 3Department of Infectious Diseases, Singapore General Hospital, Outram Road, 169608,
Singapore, and 4Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road,
169608, Singapore

Address reprint requests to: Sharifah Munirah binte Abdullah Alhamid, Medicine Academic Clinical Programme Office,

Downloaded from by guest on August 18, 2016

Singapore General Hospital, Block A Level 6, 226 Outram Road, 169039, Singapore. Tel: +65 6576 2827;
E-mail: sharifahmunirah.abdullahalhamid@mohh.com.sg
Accepted 15 June 2016

Abstract
Problem: Effective handovers are critical for patient care and safety. Electronic handover tools are
increasingly used today to provide an effective and standardized platform for information exchange.
The implementation of an electronic handover system in tertiary hospitals can be a major challenge.
Previous efforts in implementing an electronic handover tool failed due to poor compliance and buy-
in from end-users. A new electronic handover tool was developed and incorporated into the existing
electronic medical records (EMRs) for medical patients in Singapore General Hospital (SGH).
Initial assessment: There was poor compliance by on-call doctors in acknowledging electronic
handovers, and lack of adherence to safety rules, raising concerns about the safety and efficiency of
the electronic handover tool. Urgent measures were needed to ensure its safe and sustained use.
Solution: A quality improvement group comprising stakeholders, including end-users, developed
multi-faceted interventions using rapid PDSA (P-Plan, D-Do, S-Study, A-Act ) cycles to address
these issues.
Implementation: Innovative solutions using media and online software provided cost-efficient
measures to improve compliance.
Evaluation: The percentage of unacknowledged handovers per day was used as the main outcome
measure throughout all PDSA cycles. Doctors were also assessed for improvement in their knowl-
edge of safety rules and their perception of the electronic handover tool.
Lessons learnt: An electronic handover tool complementing daily clinical practice can be success-
fully implemented using solutions devised through close collaboration with end-users supported
by the senior leadership. A combined ‘bottom-up’ and ‘top-down’ approach with regular process
evaluations is crucial for its long-term sustainability.

Key words: patient handovers, electronic handover, quality improvement, patient safety

© The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved.
For permissions, please e-mail: journals.permissions@oup.com 1
2 Alhamid et al.
Problem
Effective patient handovers are critical for patient care and safety
[1]. This is ever more crucial with the restriction of junior doctors’
working hours, resulting in more patient handovers, and conse-
quently, greater potential for breakdowns in communication [2–8].
The diversity of handover practices with their variable quality and
structure can translate to medical errors, delays in treatment and
additional tests with consequent longer hospitalization, leading to
poor provider and patient satisfaction [9–11]. Verbal handovers are
often incomplete, with the omission of pertinent information,
coupled with poor retention of information by the incoming care
provider [12].
Electronic handover tools have been described in several studies
to be able to help overcome the deficits of variable and unstructured
forms of clinical handover [13–15]. They have been implemented
across various transitions of care, including the handover of patients
from the emergency department to the medical ward, the handover
of acute orthopedic admissions during change of doctor shifts and
the handover of pending tasks for medical patients to the covering
after-hours team at night and on weekends [16–18].
An electronic handover tool had been previously implemented
for patients under the Division of Medicine in Singapore General
Hospital (SGH). However, the usage of this electronic handover
tool declined with time, and operations ceased 6 months after its
implementation. Reasons for the poor sustainability of this attempt
to implement electronic handover include technical factors such as
numerous data entry fields, making the tool time-consuming and
inefficient to use, and cultural factors such as poor buy-in with min-
imal assimilation into daily practice by end-users. In addition, sys-
temic issues such as lack of a central policing team and senior
enforcement also contributed to its expiration.
Background
SGH is a 1500 patient-bed tertiary care university-affiliated teaching
hospital. Medical patients are cared for during the day by
consultant-led teams within each medical sub-specialty. After office
hours, coverage is geographical determined by ward locations.
Junior doctors pooled from different medical specialties are sched-
uled to provide after-hours coverage.
We enlisted information technology (IT) experts to re-design the
handover tool. The handover tool which is embedded in our existing
electronic medical records (EMRs) software ‘Sunrise Clinical
Manager’ (SCM) by AllscriptsTM is used daily by all healthcare pro-
viders to access patient records, investigations, and to enter daily
clinical parameters and medical notes, in addition to ordering inves-
tigations and treatments. The handover tool was created for day-
team doctors to handover pending tasks to the after-hours team,
also known as the ‘on-call’ team. Some examples of typical tasks
include tracing pending investigation results and reviewing ill
patients at night.
Learning from previous experience, we re-designed the template
with the end-user in mind. Our objective was to create a tool that was
easy to use, efficient and concise. We used guidelines from the British
Royal College of Physicians to determine which information was neces-
sary in the handover [19, 20]. We reduced the number of required data
entry fields to four, in order to fit everything within one screen (Fig. 1).
Doctors were encouraged to enter information using the well-evidenced
SBAR (S-Situation, B-Background, A-Assessment, R-Request) frame-
work. The creation and acknowledgment of handover flags are
demonstrated in Fig. 1. All handover entries are electronically dated,
timed and signed with the doctors’ names. Safety rules were established
in order to ensure timely and effective transfer of information between
the day-team and the on-call team (Table 1).
Baseline measurement
Following the implementation of the new system, key safety and effi-
ciency issues were identified. The most pressing issue was the non-
adherence to the safety rules. This raised safety concerns regarding
the possibility of missed handovers. In addition, on-call doctors
were not complying with the practice of acknowledging the hand-
over flags, rendering the handover system inefficient, due to the
accumulation of unacknowledged handover flags from the day
before. We monitored the number of handover flags raised per day
and the number of flags left unacknowledged the next morning. In
the first 3 months since the launch date, an average of 6.7% (119/
1170) of handover flags per day remained unacknowledged by the
next morning. Many doctors raised valid concerns regarding the
non-compliance with safety rules by other doctors, and its impact
on patient safety and efficiency of work at night.
Choice of solution
Engaging end-users was imperative in ensuring sustained use of the
handover tool. Thus we embarked on a quality improvement strat-
Downloaded from by guest on August 18, 2016
egy that combined a ‘bottom-up’ and ‘top-down’ approach. The
team, led by internal medicine residents, was backed by senior clini-
cians, administrative and IT members who worked to evaluate these
implementation issues, and to develop strategies using rapid PDSA
cycles. Residents gathered feedback from the ground and contacted
the relevant doctors who were not compliant. This information was
crucial in identifying critical gaps in the system, and to reveal any
near misses and adverse events, with the aim of rectifying these pro-
blems in the shortest possible time. We recognized that establishing
a safe and efficient handover platform was foremost in ensuring its
sustained use. Hence we focused on two areas for rapid improve-
ment: the education of safety rules and the compliance with the
practice of acknowledging handover flags. Senior clinicians’
endorsement was sought for all interventions.
Implementation
PDSA Cycle 1
The team residents led two educational and feedback sessions to
highlight the safety rules to doctors during teaching lectures.
Senior clinicians’ endorsement was capitalized to increase attend-
ance rates.
A reminder protocol was initiated to remind on-call doctors to
check for and to acknowledge handovers during their shift. The
rationale behind this was to encourage assimilation of the new sys-
tem. Residents shared the task of reminding on-call doctors before
their calls and also made follow-up phone calls to doctors who were
not compliant. This enabled the team to identify any barriers that
could be affecting compliance. This task took an estimated 30 min-
utes per day to complete.
PDSA Cycle 2
We improvised the reminder protocol from PDSA Cycle 1 to include
a text message reminder to the on-call doctors before their shift,
Interventions to improve efficiency, safety and sustainability • Quality Assessment
1 Patient requiring handover selected.
Doctor indicate if tracing results or if patient
3 review is required. Patient acuity is stated in
DIL (dangerously ill) box.
4 On-call doctor acknowledges
handover when task completed.
5 A red flag appears next to patient's name when handover created. This flag disappears when the handover acknowledged.
Figure 1 Electronic handover tool demonstrating creation and acknowledgment of handover (1–4) and patient list with handover flags (5).
calling doctors only when they were not compliant. The team resi-
dents sent these text messages during their free time. This took an
estimated 20 minutes per day to perform.
PDSA Cycle 3
Educational posters were designed to increase the awareness of the
safety rules. These posters were strategically displayed all over the
campus, especially at locations junior doctors frequented. This
included the on-call bedrooms, the doctors’ lounge, computer sta-
tions and even toilet cubicles adjacent to the doctors’ lounge.
The reminder protocol was further revised. We used an internet-
based software to send pre-set timed text reminders to the on-call
doctors twice during each call shift; before the start and at the end
of each call shift. A standard template was used for all messages.
This task required the manual entry of mobile numbers of the on-
call doctors working every night into the system. An administrative
team member performed this task at the start of each week, which
took an estimated 60 minutes per week to complete.
3
Information entered in SBAR format in
2 message box by day doctor.
Downloaded from by guest on August 18, 2016
PDSA Cycle 4
Educational measures were stepped up. The team designed a video
tutorial focusing on how to use the handover tool, while highlight-
ing the importance of adhering to the safety rules. Doctors had to
complete an online quiz that assessed their understanding of the
safety rules and were required to score full marks in order to receive
a certificate, as proof of completing the quiz. Senior clinicians from
the team sought support from the heads of each medical department
to mandate the completion of the quiz by all junior doctors prior to
the start of their first call.
Evaluation
Quantitative outcomes
We evaluated the period from the launch date 17 February 2014 to
the 31 December 2014 for quantifiable outcomes. This period con-
sisted of four different rotations of junior doctors. We calculated the
percentage of unacknowledged handover flags per day as the main
outcome measure represented by a statistical control chart (Fig. 2).
4 Alhamid et al.
Table 1 Safety rules for electronic handover and logic underlying rules
Safety rules
Verbal handover for late handovers
All electronic handovers created after 6 pm on weekdays and 1 pm on
weekends and public holidays must be accompanied by phone call to
on-call doctor.
Verbal handover for selected patients
All electronic handovers must be accompanied by a verbal call to on-
call doctor for:
(a) Patients requiring reviews at night
(b) Patients who are dangerously-ill (DIL)
All handovers must be acknowledged by 8 am next day
Electronic handovers for inpatients located in emergency department
are not allowed
60%
Percentage of unacknowledged flags per day
PDSA 1
Daily calling
50%
40%
30%
20%
10%
0%
Feb Mar
Qualitative outcomes measured during April to June
Figure 2 P chart of percentage of unacknowledged handover flags per day (17th Feb 2014 to 31st December 2014).
Non-compliance rate
The reminder protocols used in PDSA Cycles 1 and 2 did not result
in a significant change in compliance, with an average of 6.7%
(203/3043) of handovers remaining unacknowledged each day. In
addition, large variations in non-compliance were seen in the initial
months post-implementation, as expected in a new system. In April,
a changeover of doctors resulted in special cause variation, as the
new doctors were not familiar with the system. These doctors were
identified and ad hoc education was provided, and this variation
was eliminated.
PDSA Cycle 3, which featured a revised reminder protocol using
pre-set timed text reminders, significantly improved the system’s
capability in reducing the average percentage of unacknowledged
flags per day from 6.7% (203/3043) to 2.2% (140/6248). However,
special cause variations were noted on five occasions. These were
attributed to new doctors rotating into the division outside the usual
rotation cycle, and doctors who were rotating from other institu-
tions. In addition, the use of this electronic handover system had
Logic
Promote system safety and work efficiency
To prevent dropped handovers due to late creation of handovers.
On-call doctors do not need to keep checking system for new handovers
after the cut-off periods.
Promote patient safety
To allow two-way clarification for patients who are more ill and whose
conditions are more complex than others.
Promote system efficiency
To prevent accumulation of handover flags from previous days. The
accumulation of old and new handover flags will inundate system, and
may make work more inefficient for doctors.
Promote system safety
To prevent dropped handovers due to change of patient’s location.
Patients awaiting bed allocation may be transferred to any available ward,
at any time. Electronic handovers can be missed, as on-call doctors may
not be aware of patient’s transfer into their ward coverage.
PDSA 2
Single text message PDSA 3
Downloaded from by guest on August 18, 2016
Educational posters and timed twice-daily messages PDSA 4
Mandatory online educational video
and quiz
Upper control limit
Apr May Jun Jul Aug Sep Oct Nov Dec
spread to three other departments who had begun implementing the
system for their patients in July. This increased the number of doc-
tors who were new to the electronic handover system, causing a
higher occurrence of special cause variations. These doctors were
identified and ad hoc education was given.
PDSA Cycle 4 was launched to address the recurring need of
educating new doctors. An online video tutorial was designed and
mandated for new doctors rotating into all departments using the
electronic handover system. This further improved the system’s cap-
ability in reducing the average percentage of unacknowledged flags
from 2.2% (106/4925) to 1.4% (74/5114). During this period, two
special cause variations were noted. This was attributed to specific-
ally one doctor in October and two doctors in December who were
not compliant with the system. On these occasions, which were rare,
senior clinicians on the team would step up to reiterate the import-
ance of compliance to these doctors. There were no critical inci-
dences or adverse patient events reported throughout the study
period.
Interventions to improve efficiency, safety and sustainability • Quality Assessment
Clinical utility
The use of the electronic handover system remained stable through-
out the study. The overall median percentage of handovers created
per medical inpatients per day was 7.3%, increasing to 8.1% after
the 1st of July with three more departments using the system. The
median number of medical patients in the general wards per day
before and after 1st July was 427 (range 360 to 526) and 698 (range
567 to 805) respectively.
Qualitative outcomes
In our institution, junior doctors switch departments every 3
months. Hence qualitative measures had to be assessed across the
specific 3-month rotation of doctors in order to draw meaningful
comparisons before and after intervention. We evaluated the cohort
of doctors rotating during April to June for their knowledge of
safety rules and perception towards the electronic handover. PDSA
Cycle 3, which was our most significant intervention, was initiated
during this period.
A questionnaire was administered at the start and end of the
evaluation period (e-supplement 1). A total of 42 doctors completed
both the pre- and post-intervention questionnaires, representing
62% of the total cohort of doctors during this period. We used
Wilcoxon signed ranked test with two-tailed values to analyze the
data.
Doctors were given a list of statements relating to the safety rules
and were asked to select which rules were true. There was a signifi-
cant increase in the percentage of correct responses post-
intervention for all rules (P = 0.01) (Fig. 3). We also assessed doc-
tors’ perception of the electronic handover tool with regards to
improving patient safety, work efficiency and accountability. There
was an overall positive response, with an increase in the percentage
of doctors selecting ‘strongly agree and agree’ post-intervention,
especially in the area of improving patient safety (P = 0.05) (Fig. 4).
Lessons learnt
The importance of engaging medical staff who are the end-users of
the electronic handover tool cannot be overstated, as this helps
ensure the sustainability of the new system. This echoes previous
studies that have reiterated the absolute need to engage practicing
medical staff when implementing and designing electronic handover
tools [21–24]. We prioritized safety as a key issue and worked to
earn the doctors’ trust in and reliance on the system.
We learnt to stop protocols that did not work, early in the study,
and to use technology to deliver interventions that were consistent
PRE-INTERVENTION
VERBAL HANDOVER NEEDED AFTER 6PM
VERBAL HANDOVER NEEDED AFTER 1PM
NO ELECTRONIC FLAGS FOR A&E
ON-CALL MUST ACKNOWLEDGE ALL FLAGS
Figure 3 Percentage of correct answers to safety rules. A&E, accident and emergency.
5
and sustainable. The reminder protocol that used an internet-based
software in PDSA Cycle 3 had the most impact in reducing non-
compliance, as reminders were sent out in a timely and consistent
fashion. This intervention also proved to be cost-effective reducing
the total manpower hours from 210 minutes to 60 minutes required
per week. Similarly, in PDSA Cycle 4, the online educational tutorial
was a more efficient and sustainable solution compared to educa-
tional posters and ad hoc education. The use of online media was
especially useful in reaching a wider audience with the regular
changeover of doctors every 3 months, across 11 departments. The
reminder protocol and online educational video interventions are
still in use today. We also learnt that senior endorsement is crucial
in overcoming logistical and organizational barriers to change.
Their support provided access to administrative and IT experts
who make up the administrative backbone of the complex health-
care system today.
The success of the implementation of the electronic handover
tool was in part due to the inherent advantage of embedding elec-
tronic handover into the existing EMR. This allowed for a highly
integrated ‘live’ platform, with real-time updates of patient informa-
tion, obviating the need to duplicate data entry, thereby minimizing
communication process errors [25]. This also spared clinicians from
having to learn how to use another software, which is always a hur-
dle when any new system is implemented.
The improved documentation of clinical handovers as a result of
the electronic handover system was a delightful bonus. The ‘who’,
‘what’, ‘where’, ‘when’ and ‘how’ of clinical handovers are now
Downloaded from by guest on August 18, 2016
transparent to all, with an electronic trail, ensuring accountability.
This has also provided evidence of information exchange, which is
crucial in potential medico-legal cases [26]. The use of this handover
tool has since been modified for use in another tertiary hospital in
Singapore.
Limitations
Our study has several limitations. Firstly, we recognize there was no
single quantifiable measure that could accurately reflect all aspects
of improvement of the handover tool. We chose to measure the rate
of non-compliance as an overall surrogate measure of adherence to
the safety rules, and indirectly, overall buy-in and cultural assimila-
tion. Secondly, we were not able to assess the knowledge and per-
ception of doctors for every PDSA cycle. This was due to logistical
and timing difficulties in synchronizing PDSA cycles with the
changeover dates of doctors. Thirdly, the response rate of 62%
may not be reflective of all doctors present. The completion of the
POST-INTERVENTION p = 0.01
79%
97%
76%
94%
79%
88%
88%
97%
6 Alhamid et al.
Strongly agree/agree
IMPROVED PATIENT SAFETY (PRE)
IMPROVED PATIENT SAFETY (POST)
IMPROVED DOCTORS’ WORKSFLOW (PRE)
IMPROVED DOCTORS’ WORKFLOW (POST)
INCREASED ACCOUNTABILITY FOR ON-CALL (PRE)
INCREASED ACCOUNTABILITY FOR ON-CALL (POST)
INCREASED ACCOUNTABILITY FOR PRIMARY TEAM (PRE)
INCREASED ACCOUNTABILITY FOR PRIMARY TEAM (POST)
Figure 4 Comparison of doctors’ perceptions of the electronic handover tool pre- and post-intervention.
questionnaires was voluntary. However, the most significant improve-
ment was seen in PDSA Cycle 3. This was mirrored by an improve-
ment in the knowledge of safety rules, and an improvement in
doctors’ perception of the electronic handover tool, particularly with
regard to patient safety. We can therefore deduce that the sustained
trend of improvement in compliance had translated to a safer and
more efficient electronic platform for handover. This trend was fur-
ther strengthened in PDSA Cycle 4 achieving the lowest rate of non-
compliance. This suggests that cultural assimilation of the handover
tool into daily clinical practice had occurred, reflecting buy-in.
Finally the study was not designed to assess the quality of the
information exchange during the handovers, a key area for improve-
ment. This was deliberate, as we wanted to focus on ensuring the
sustained use of the handover tool before targeting other areas for
improvement. We have since embarked on a second quality
improvement initiative to assess and improve the quality of the con-
tent of handovers using the SBAR framework.
Conclusion
Our experience demonstrates that electronic handover can be safely,
effectively and sustainably implemented for medical patients residing
in the general wards, in a busy tertiary care teaching hospital. In
concurrence with strategies previously described, this was achieved
through close collaboration amongst end-users, senior leadership,
administrative and IT staff, continual education and constant reeva-
luations to identify problems and effect solutions [27]. The use of
media and online software should be capitalized to provide simple
and cost-effective solutions particularly in today’s complex health-
care systems. We report the ongoing use of this electronic handover
system till 2016.
Authors’ contributions
All authors contributed to the design and writing, data collection
and interpretation of the results of this study.
Acknowledgements
The authors would like to acknowledge the following: A/Prof Chow Wan
Cheng, MBBS, Chairman of Division of Medicine, Singapore General Hospital;
Dr Nur Emillia binte Roslan, MBBS, Internal Medicine Residency, Singapore
Health Services, Singapore General Hospital; Dr Nurul Aidah binti Abdul
Halim, MBBCh, Internal Medicine Residency, Singapore Health Services,
Neutral Strongly disagree/disagree
34% 56% 10%
63% 29% 7%
p = 0.05
45% 43% 13%
73% 15% 13%
p = 0.11
59% 39% 2%
81% 12% 7%
p = 0.17
53% 38% 10%
68% 10% 23%
p = 1.0
Singapore General Hospital; Dr Ng Kangqi, MBBS, Internal Medicine
Residency, Singapore Health Services, Singapore General Hospital; Dr Orlanda
Goh Qi Mei, MBBS, Internal Medicine Residency, Singapore Health Services,
Singapore General Hospital; Dr Sii Sik Liong, MBBS, Internal Medicine
Residency, Singapore Health Services, Singapore General Hospital; Dr Vignesh
s/o Sivasamy, MBBS, Internal Medicine Residency, Singapore Health Services,
Singapore General Hospital; Dr Wong Ningyan, MBBS, Internal Medicine
Residency, Singapore Health Services, Singapore General Hospital; Dr Mark
Cheah, MBBS, Internal Medicine Residency, Singapore Health Services,
Singapore General Hospital; Dr Li Weiquan James, MBBS, Internal
Downloaded from by guest on August 18, 2016
Medicine Residency, Singapore Health Services, Singapore General
Hospital; Rachael Wu Yu-ling, BSN, Division of Medicine, Singapore
General Hospital; Lin Eng Hock, BEng, Integrated Health Information
Systems Pte Ltd (IHiS); Clarence Kua Cheong Kee, BCom BIS, Integrated
Health Information Systems Pte Ltd (IHiS); Jacqueline Goh Soo Kian,
BCompSc, Integrated Health Information Systems Pte Ltd (IHiS).
References
1. The Joint Commission: The 2010 Accreditation Manual for Hospitals:
The Official Handbook. Oakbrook Terrace, IL: Joint Commission
Resources, 2009.
2. Horwitz LI, Krumholz HM, Green ML et al. Transfers of patient care
between house staff on internal medicine wards: a national survey. Arch
Intern Med 2006;166:1173–7.
3. Vidyarthi AR, Arora V, Schnipper JL et al. Managing discontinuity in
academic medical centers: strategies for a safe and effective resident sign-
out. J Hosp Med 2006;1:257–65.
4. Horwitz LI, Moin T, Krumholz HM et al. Consequences of inadequate
sign-out for patient care. Arch Intern Med 2008;168:1755–60.
5. Lofgren RP, Gottlieb D, Williams RA et al. Post-call transfer of resident
responsibility: its effect on patient care. J Gen Intern Med 1990;5:501–5.
6. Mukherjee S. A precarious exchange. N Engl J Med 2004;351:1822–4.
7. Cook RI, Render M, Woods DD. Gaps in the continuity of care and pro-
gress on patient safety. Br Med J 2000;320:791–4.
8. Petersen LA, Brennan TA, O’Neil AC et al. Does housestaff discontinuity
of care increase the risk for preventable adverse events?. Ann Intern Med
1994;121:866–72.
9. Patterson ES, Wears RL. Patient Handoffs: standardized and reliable meas-
urement tools remain elusive. Jt Comm J Qual Patient Saf 2010;36:52–61.
10. Risser DT, Rice MM, Salisbury ML et al. The potential for improved
teamwork to reduce medical errors in the emergency department. The
MedTeams Research Consortium. Ann Emerg Med 1999;34:373–83.
11. Lawrence RH, Tomolo AM, Garlisi AP et al. Conceptualizing handover
strategies at change of shift in the emergency department: a grounded the-
ory study. BMC Health Serv Res 2008;8:256.
12. Bhabra G, Mackeith S, Monteiro P et al. An experimental comparison of
handover methods. Ann R Coll Surg Engl 2007;89:298–300.
Interventions to improve efficiency, safety and sustainability • Quality Assessment
13. Barnes SL, Campbell DA, Stockman KA et al. From theory to practice of
electronic handover. Aust Health Rev 2011;35:384–91.
14. Raptis DA, Fernandes C, Chua W et al. Electronic software significantly
improves quality of handover in a London teaching hospital. Health
Inform J 2009;15:191–8.
15. Govier M, Medcalf P. Living for the weekend: electronic documentation
improves patient handover. Clin Med 2012;12:124–7.
16. Gonzalo JD, Yang JY, Stuckey HL et al. Patient care transitions from the
emergency department to the medicine ward: evaluation of a standardized
electronic signout tool. Int J Qual Health Care 2014;26:337–47.
17. Karayiannis P, Warnock J. Improving handover of acute orthopaedic
admissions. BMJ Qual Improv Rep 2015;4(1).
18. Till A, Sall H, Wilkinson J. Safe handover: safe patients—the electronic
handover system. BMJ Qual Improv Rep 2014;2(2).
19. Metz D, Chard D, Rhodes J et al. Continuity of Care for Medical
Inpatients: Standards of Good Practice. London: Royal College of
Physicians, 2004.
20. Royal College of Physicians Guide for Trainees and Trainers: General
Professional Training Guide. London: RCP, 2005.
7
21. Jha AK, DesRoches CM, Campbell EG et al. Use of electronic health
records in US hospitals. N Engl J Med 2009;360:1628–38.
22. Showell C, Thomas M, Wong MC et al. Patient safety and sociotechnical
considerations for electronic handover tools in an Australian ehealth land-
scape. Stud Health Technol Inform 2010;157:193–8.
23. Clark CJ, Sindell SL, Koehler RP. Template for success: using a resident-
designed sign-out template in the handover of patient care. J Surg Educ
2011;68:52–7.
24. Wong MC, Cummings E, Turner P. User-centered design in clinical hand-
over: exploring post-implementation outcomes for clinicians. Stud Health
Technol Inform 2013;192:253–7.
25. Cheah LP, Arnott DH, Pollard J et al. Electronic medical handovers:
towards safer medical care. Med J Aust 2005;183:369–72.
26. Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann
Intern Med 2005;142:352–8.
27. Clarke CM, Persaud DD. Leading clinical handover improvement: a
change strategy to implement best practices in the acute care setting.
J Patient Saf 2011;7:11–8.
Downloaded from by guest on August 18, 2016