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Sykes M, Garnham J, Kostelec PM, Hall H, Mitra A. Assessment and improvement of junior doctor handover in the emergency department. BMJ Open Qual 2020; 9:bmjoq-2020-001032. [PMID: 32816811 PMCID: PMC7437714 DOI: 10.1136/bmjoq-2020-001032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/21/2020] [Accepted: 07/27/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction Effective handover between junior doctors is widely accepted as essential for patient safety. The British Medical Association in association with the National Health Service (NHS) National Patient Safety Agency and NHS Modernisation Agency have produced clear guidance regarding the contents and setting for a safe and efficient handover. We aimed to understand current junior doctor’s opinions on the handover process in a London emergency department (ED), with subsequent assessment, and any necessary improvement, of handover practices within the department. Methods In a London ED, a baseline survey was completed by the senior house officer (SHO) cohort to gauge current opinions of the existing handover process. Concurrently, a blinded prospective audit of handover practises was conducted. Multiple improvement strategies were subsequently implemented and assessed via Plan–Do–Study–Act (PDSA) cycles. A standard operating procedure was initially introduced and ‘rolled out’ throughout the department. This intervention was followed by development of an electronic handover note to ease completion of a satisfactory handover. Additional surveys were conducted to continually assess SHO opinion on how the handover process was developing. The final improvement strategy was formal handover teaching at the SHO induction. Results Baseline audit and SHO survey highlighted several opportunities for improvement. 5 handover components were deemed essential: (1) documented handover note; (2) doctor’s names; (3) history of presenting complaint; (4) ED actions; and (5) ongoing plan. The frequency of these components saw significant improvement by completion of the final PDSA. Following SHO rotation, all of the essential components fell, only to recover after the next improvement strategy. Conclusions Junior doctors in a London ED were not satisfied with the current SHO handover process, and handover practices were not adequate. While the rotational nature of the SHO cohort makes sustained change challenging, implementation of thoughtful and realistic improvement strategies can significantly improve handover quality.
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Affiliation(s)
- Mark Sykes
- Trauma and Orthopaedic Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jack Garnham
- Emergency Department, Charing Cross Hospital, London, UK
| | | | - Hazel Hall
- Emergency Department, Charing Cross Hospital, London, UK
| | - Anu Mitra
- Emergency Department, Charing Cross Hospital, London, UK
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Mounsey SJ, Amer H, Yeung M. Introduction of an electronic weekend handover system at a London university teaching hospital. Future Healthc J 2018; 5:224-228. [PMID: 31098571 PMCID: PMC6502606 DOI: 10.7861/futurehosp.5-3-224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Handover has long been identified as a potential source for error that can have direct consequences for patient care. The current weekend handover system at University College Hospital, London, involved a verbal handover meeting with a variety of methods used to collate information. A new handover system was introduced that involved the pre-population of a spreadsheet before attending the handover meeting. Doctors involved in the handover process were canvassed for opinion before and after the introduction of the new system, and logistical data were collected. The new system reduced the amount of time spent preparing for, and delivering, handover, and was deemed to be safer and to improve adherence to the Royal College of Physicians' guidelines for handover, including specification of level of doctor to perform handover and prioritisation of handover.
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Affiliation(s)
| | - Halima Amer
- Clinical Pharmacology and Therapeutics, University College London Hospital, London, UK
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Maroo S, Raj D. Introducing a New Junior Doctor Electronic Weekend Handover on an Orthopaedic Ward. BMJ QUALITY IMPROVEMENT REPORTS 2017; 6:bmjquality_uu212695.w5059. [PMID: 28469904 PMCID: PMC5411720 DOI: 10.1136/bmjquality.u212695.w5059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 05/03/2016] [Indexed: 11/11/2022]
Abstract
Junior Doctors working on the Orthopaedic wards at a district general hospital identified the lack of a formal weekend handover. The Royal Colleges,GMC and Foundation Programme curriculum all emphasise the importance of a safe and effective handover. Doctors found that the current system of using a written, paper-based handover was unreliable, un-legible, and inefficient. Baseline measurements were sought in the form of a questionnaire which allowed us to obtain the limitations to the current handover. After this and a focus group, a new electronic, ‘Microsoft Word’ based handover was created and a repeat surgery issued in 2 weeks. Further PDSA cycles over the course of 8 weeks helped to improve and implement the new handover. The overall rating, out of 10, of the new handover increased from 3.4 to 8. Doctors felt the new handover was safer for patients and could be used as a tool for reviewing or referring patients. This project describes the use of a simple, cost-effective intervention that helped to improve patient safety and staff satisfaction.
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Affiliation(s)
- Siddharth Maroo
- Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, UK
| | - Dipak Raj
- Pilgrim Hospital, United Lincolnshire Hospitals NHS Trust, UK
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Kostelec P, Emanuele Garbelli P, Emanuele Garbelli P. Introduction of a Microsoft Excel-based unified electronic weekend handover document in Acute and General Medicine in a DGH: aims, outcomes and challenges. BMJ QUALITY IMPROVEMENT REPORTS 2017; 6:u212152.w5721. [PMID: 28352468 PMCID: PMC5361068 DOI: 10.1136/bmjquality.u212152.w5721] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 02/23/2017] [Indexed: 11/17/2022]
Abstract
On-call weekends in medicine can be a busy and stressful time for junior doctors, as they are responsible for a larger pool of patients, most of whom they would have never met. Clinical handover to the weekend team is extremely important and any communication errors may have a profound impact on patient care, potentially even resulting in avoidable harm or death. Several senior clinical bodies have issued guidelines on best practice in written and verbal handover. These include: standardisation, use of pro forma documents prompting doctors to document vital information (such as ceiling of care/resuscitation status) and prioritisation according to clinical urgency. These guidelines were not consistently followed in our hospital site at the onset of 2014 and junior doctors were becoming increasingly dissatisfied with the handover processes. An initial audit of handover documents used across the medical division on two separate weekends in January 2014, revealed high variability in compliance with documentation of key information. For example, ceiling of care was documented for only 14-42% of patients and resuscitation status in 26-72% of patients respectively. Additionally, each ward used their own self-designed pro forma and patients were not prioritised by clinical urgency. Within six months from the introduction of a standardised, hospital-wide weekend handover pro forma across the medical division and following initial improvements to its layout, ceiling of therapy and resuscitation status were documented in approximately 80% of patients (with some minor variability). Moreover, 100% of patients in acute medicine and 75% of those in general medicine were prioritised by clinical urgency and all wards used the same handover pro forma.
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Affiliation(s)
- Pablo Kostelec
- Princess Royal University Hospital, King's College Hospital, UK
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Saifuddin A, Magee L, Barrett R. "Chase CRP", "Review patient": Improving the Quality of Weekend Medical Handover at a London Teaching Hospital. BMJ QUALITY IMPROVEMENT REPORTS 2016; 4:bmjquality_uu201656.w1919. [PMID: 26732516 PMCID: PMC4693101 DOI: 10.1136/bmjquality.u201656.w1919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 11/22/2015] [Indexed: 11/04/2022]
Abstract
Clinical handover has been identified as a "major preventable cause of harm" by the Royal College of Physicians (RCP). Whilst working at a London teaching hospital from August 2013, we noted substandard weekend handover of medical patients. The existing pro forma was filled incompletely by day doctors so it was difficult for weekend colleagues to identify unwell patients, with inherent safety implications. Furthermore, on-call medical staff noted that poor accessibility of vital information in patients' files was affecting acute clinical management. We audited the pro formas over a six week period (n=83) and the Friday ward round (WR) entries for medical inpatients over two weekends (n=84) against the RCP's handover guidance. The results showed poor documentation of several important details on the pro formas, for example, ceiling of care (4%) and past medical history (PMH) (23%). Problem lists were specified on 62% of the WR entries. We designed new handover pro formas and 'Friday WR sheets' to provide prompts for this information and used Medical Meetings and emails to explain the project's aims. Re-audit demonstrated significant improvement in all parameters; for instance, PMH increased to 52% on the pro formas. Only 10% of Friday WR entries used our sheet. However, when used, outcomes were much better, for example, problem list documentation increased to 100%. In conclusion, our interventions improved the provision of crucial information needed to prioritise and manage patients over the weekend. Future work should further highlight the importance of safe handover to all doctors to induce a shift in culture and optimise patient care.
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Michael E, Patel C. Improving medical handover at the weekend: a quality improvement project. BMJ QUALITY IMPROVEMENT REPORTS 2015; 4:bmjquality_uu207153.w2899. [PMID: 26734385 PMCID: PMC4693034 DOI: 10.1136/bmjquality.u207153.w2899] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 02/11/2015] [Indexed: 11/17/2022]
Abstract
In recent years medical handover has been identified as an increasingly important area for hospitals to improve upon, in light of the changes in shift patterns for doctors. Significant changes to weekday handover had recently been successfully introduced at Broomfield hospital. Weekend handover remained a concern, with an electronic and paper system being used simultaneously. Our objectives were to introduce a new electronic handover system for weekend handover at Broomfield Hospital and improve the organisation of the weekend handover meeting to promote patient safety. Doctors involved in weekend handover were surveyed using a questionnaire, to establish insufficiencies in the weekend handover process; where both the electronic ExtraMed system and paper were being used inconsistently. A new weekend handover system was introduced together with a new user-friendly electronic handover database, addressing the identified difficulties in the current system. These changes met the medical handover guidelines set by the Royal College of Physicians. Three months after the launch of the new system, doctors were re-surveyed using a modified questionnaire to assess the impact our changes had made. Before changes were implemented only 12% of doctors surveyed used the electronic system for weekend. Eighty-nine percent found sorting through jobs time consuming and 67% were handed jobs to them meant for a different grade of doctor. Only 41% were aware who to hand weekend discharges to. Subjective assessment of safety was 3.18 out of 5. The electronic system was felt to be time consuming and complicated. After execution of the new weekend handover process, 100% of doctors reported using the electronic system for weekend handover. Only 47% of doctors felt sorting through jobs was time consuming and 89% of doctors were aware who to handover weekend discharges to. Subjective assessment of the safety of weekend handover improved to 3.84 out of 5. Informal interviews on the ward revealed a high degree of satisfaction with the new weekend handover system. In conclusion we found that a structured, well organised weekend handover meeting together with an effective electronic handover system improves the quality of medical weekend handover.
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Sneller S, Lada K, Turner C, Millwood S, Jervis B, Barr J, Farrell L. Improving the quality of weekend handover at Yeovil District Hospital. BMJ QUALITY IMPROVEMENT REPORTS 2014; 3:bmjquality_uu203647.w1613. [PMID: 26733188 PMCID: PMC4645700 DOI: 10.1136/bmjquality.u203647.w1613] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 06/19/2014] [Accepted: 09/02/2014] [Indexed: 11/03/2022]
Abstract
"Handover of care is one of the most perilous procedures in medicine" (British Medical Association, Safe Handover, Safe Patients). The system in place for weekend handover at YDH was deemed disorganised, unstructured and frequently missing key pieces of information, leaving the on-call Foundation Year 1 (FY1) doctor with only vague jobs and management plans. Baseline surveys demonstrated that junior doctors felt the system was inadequate, potentially compromised patient safety and increased their stress levels. In order to improve this problem a structured weekend handover proforma was created, comparable with the "Out of hours handover record keeping standards: template" from the Royal College of Physicians. This was made readily accessible on the local intranet. Education sessions were organised for the FY1 and FY2 doctors. The impact of the newly introduced proforma was measured using feedback surveys each week from the FY1 on ward cover for six months. A further change implemented was the introduction of a Friday Ward Round proforma. The aim was to reduce the time required to review notes by the on-call doctor, to minimise avoidable weekend jobs and to improve compliance with the management plans. The results demonstrated 100% compliance with the new proformas. There were notable improvements in the presence of a plan (37.5% to 91.7%, max. 100%), a minimum of two patient identifiers (68.8% to 100%) and relevant background information (62.5% to 100%). Qualitative data showed a much higher level of satisfaction with the new system. Future plans include rolling out electronic handover to improve problems such as illegible handwriting and missing data (enable 'compulsory' fields), and also for this system to be implemented Trust-wide.
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Reed O. Improving the medical 'take sheet'. BMJ QUALITY IMPROVEMENT REPORTS 2014; 3:u202917.w1357. [PMID: 26734303 PMCID: PMC4645921 DOI: 10.1136/bmjquality.u202917.w1357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 03/20/2014] [Indexed: 11/29/2022]
Abstract
The GMC states that "Trainees in hospital posts must have well organised handover arrangements, ensuring continuity of patient care[1]". In the Belfast City Hospital throughout the day there can be multiple new medical admissions. These can be via the GP Unit, transfers for tertiary care, and transfers due to bed shortages in other hospitals. Over the course of 24 hours there can be up to four medical SHOs and three registrars that fill in the take sheet. Due to the variety of admission routes and number of doctors looking after the medical take information can be lost during handover between SHOs. In the current format there is little room to write and key and relevant information on the medical take sheet about new and transferring patients. I felt that this handover sheet could be improved. An initial questionnaire demonstrated that 47% found the old proforma easy to use and 28.2% felt that it allowed them to identify sick patients. 100% of SHOs and Registrars surveyed felt that it could be improved from its current form. From feedback from my colleagues I created a new template and trialled it in the hospital. A repeat questionnaire demonstrated that 92.3% of responders felt the new format had improved medical handover and that 92.6% felt that it allowed safe handover most of the time/always. The success of this new proforma resulted in it being implemented on a permanent basis for new medical admissions and transfers to the hospital.
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Mehra A, Henein C. Improving hospital weekend handover: a user-centered, standardised approach. BMJ QUALITY IMPROVEMENT REPORTS 2014; 2:bmjquality_uu202861.w1655. [PMID: 26734248 PMCID: PMC4663852 DOI: 10.1136/bmjquality.u202861.w1655] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 01/14/2014] [Accepted: 01/28/2014] [Indexed: 11/04/2022]
Abstract
Clinical Handover remains one of the most perilous procedures in medicine (1). Weekend handover has emerged as a key area of concern with high variability in handover processes across hospitals (1,2,4, 5-10). Studying weekend handover processes within medicine at an acute teaching hospital revealed huge variability in documented content and structure. A total of 12 different pro formas were in use by the medical day-team to handover to the weekend team on-call. A Likert-survey of doctors revealed 93% felt the current handover system needed improvement with 71% stating that it did not ensure patient safety (Chi-squared, p-value <0.001, n=32). Semi-structured interviews of doctors identified common themes including "a lack of consistency in approach" "poor standardization" and "high variability". Seeking to address concerns of standardization, a standardized handover pro forma was developed using Royal College of Physician (RCP) guidelines (2), with direct end-user input. Results following implementation revealed a considerable improvement in documented ceiling of care, urgency of task and team member assignment with 100% uptake of the new proforma at both 4-week and 6-month post-implementation analyses. 88% of doctors surveyed perceived that the new proforma improved patient safety (p<0.01, n=25), with 62% highlighting that it allowed doctors to work more efficiently. Results also revealed that 44% felt further improvements were needed and highlighted electronic solutions and handover training as main priorities. Handover briefing was subsequently incorporated into junior doctor induction and education modules delivered, with good feedback. Following collaboration with key stakeholders and with end-user input, integrated electronic handover software was designed and funding secured. The software is currently under final development. Introducing a standardized handover proforma can be an effective initial step in improving weekend handover. Handover education and end-user involvement are key in improving the process. Electronic handover solutions have been shown to significantly increase the quality of handover and are worth considering (9, 10).
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Affiliation(s)
- Avi Mehra
- Brighton & Sussex University Hospitals NHS Trust
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10
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Bethune R, Campbell K, Rose A, Wassall R, Price C, Siese T, Finn R, Whitaker S. Improving weekend handover between junior doctors on medical and surgical wards. BMJ QUALITY IMPROVEMENT REPORTS 2014; 2:bmjquality_uu483.w1045. [PMID: 26734230 PMCID: PMC4663809 DOI: 10.1136/bmjquality.u483.w1045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 11/14/2013] [Accepted: 01/03/2014] [Indexed: 11/19/2022]
Abstract
Poor weekend handover has been implicated as one of the causes of observed higher mortality rates at weekends in UK hospitals. In a large teaching hospital we, a group of junior doctors, set about improving the quality and effectiveness of weekend handover. We used the Model for Improvement to implement a weekend handover sticker through an iterative process using multiple Plan/Do/Study/Act (PDSA) cycles. Over the 16 week study period the number of completed weekend tasks increased by 30% and the number of patients with a documented weekend handover increased by nearly 50%. Junior doctors are well positioned to notice the quality and safety shortcomings within hospitals, and by using effective improvement methods they can improve these systems at little or no cost.
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Palmer E, Richardson E, Newcombe H, Borg CM. The F.R.I.D.A.Y.S. checklist - Preparing our patients for a safe weekend. BMJ QUALITY IMPROVEMENT REPORTS 2013; 2:bmjquality_uu660.w502. [PMID: 26734210 PMCID: PMC4663813 DOI: 10.1136/bmjquality.u660.w502] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 10/31/2013] [Indexed: 11/30/2022]
Abstract
There is a higher incidence of mortality and adverse events among inpatients in UK hospitals at the weekend compared to weekdays. The high volume of routine tasks handed over by the weekday doctors on Fridays may be a contributing factor. An audit was carried out on four acute wards on a Friday evening at University Hospital Lewisham (UHL). It demonstrated that most patients had at least one outstanding task that would need completing by the on-call team over the weekend. To address this problem a concise and memorable checklist was created to ensure that routine jobs are completed by the weekday team prior to the weekend. The checklist uses the acronym “F.R.I.D.A.Y.S.” to prompt doctors to hand over weekend bloods, ensure drug charts are reviewed, document a plan for IV fluids, complete discharge summaries, monitor antibiotic levels, dose warfarin, and clearly document the ceiling of care. The F.R.I.D.A.Y.S. checklist was printed onto history paper and integrated into the patient notes on a Friday ward round. The efficacy of the checklist was evaluated by reviewing the number of outstanding jobs on the wards after 17:00 on a Friday in the categories listed. F-Phlebotomy R-Rewrite drug chart I-IV fluids D-Discharge summaries A-Antibiotic levels Y-Yellow book (warfarin) S-Resuscitation Status The number of outstanding jobs on a ward (A) that used F.R.I.D.A.Y.S. was 3 out of a total 132 jobs (2.3%) compared with 47 out of a total of 103 (45.6%) on a ward that did not use the checklist (B). When the F.R.I.D.A.Y.S. checklist is implemented there is an increase in the number of routine jobs that are carried out by the weekday team, and therefore a reduction in workload for the weekend on call team. Patient safety is improved as management decisions are made by a team that is familiar with the patient, and on call teams are able to prioritise emergencies. The cost saving of using the F.R.I.D.A.Y.S. checklist if implemented throughout UHL is estimated at £317,136 per annum.
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Ashton C. Improving weekend patient handover. BMJ QUALITY IMPROVEMENT REPORTS 2013; 2:bmjquality_uu201303.w827. [PMID: 26734216 PMCID: PMC4663824 DOI: 10.1136/bmjquality.u201303.w827] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 10/25/2013] [Indexed: 11/10/2022]
Abstract
The Royal College of Physicians state that ‘handover, particularly of temporary ‘on-call’ responsibility, has been identified as a point at which errors are likely to occur’ [1]. Working a weekend on-call covering medical wards is often busy and stressful for all junior doctors, with added pressure in trying to identify patients and tasks amongst several different pieces of paper and making important care escalation. All handover sheets from a random weekend were collected and studied. Only 57% of patients listed had the minimum expected 3 patient identifiers [2] included and just 11% had any indication of escalation planning. They were also often written on scrap pieces of paper and included varying levels of relevant patient background and information. After liaison with junior doctors and the handover committee, involving senior medical clinicians, a new handover sheet was created and uploaded onto the trust intranet, to rectify some of the problems identified. Junior doctors were also educated about the changes to weekend handover. At 2 months post-introduction, another set of weekend handover sheets were collected. All medical wards used the handover sheets for documentation of patients and tasks at a weekend and inclusion of 3 patient identifiers rose to 80%. There was also a big increase noted in clinical information and background included at weekend handover and anecdotally made weekend handover easier and less stressful. There was also increased consideration of escalation planning. The handover sheet is now being rolled out trust-wide in medicine and introduced to surgical colleagues.
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