A crucial development in patient safety, which is being rolled out this summer by the Mater Hospital, is a system for the handover of patients from one medical team to another. The tragic death of a young man at the Mater occurred as a result of organisational failure, and prompted the change. The Mater's system is reportedly pioneering in this country. The patient had major heart surgery in 2005 to change his pacemaker, and died of cardiac arrhythmia following an adverse drug reaction. His consultant had gone on leave, and there had been no formal procedure for handing his care over to another consultant. Following the incident an independent review was carried out. It concluded that a systems failure at the hospital was responsible, and recommended that a clinical handover system be introduced.1 The new system is to be introduced in July 2009 and will see a formal clinical handover of patients from one medical team to another, with a document to be signed by both the admitting and receiving consultants.2

While the failure of communication channels does not always have such tragic consequences, ensuring lines are clear will reduce risk to patients and improve the efficiency of hospitals greatly. In the interest of patient safety it is suggested that a national approach and policy should be adopted on this issue and guidance issued for all hospitals, both public and private. Speaking at a recent health information standards workshop organised by HIQA, Dr Tony Shannon, Clinical Lead of the Clinical Content Service with the NHS's Connecting for Health, noted that the development of standardised admission was an example of '[a] simple but really important clinical priorit[y]' and that Ireland could 'leverage some of [what the NHS has done] in that area and try to use it'.3

No doubt HIQA will take the lead on the issue of patient handover and communication generally between healthcare practitioners.

Litigation Implications

Hospitals and the HSE should also bear in mind that the lack of a coherent handover policy and the loss of patient information could lead to medical negligence litigation. Cases have been won in Ireland against hospitals, where injuries have been suffered owing to direct systemic or organisational negligence. In these cases the hospital breached a duty of care which they owed directly to the patient. 4 In particular, Irish courts have awarded damages against hospitals for flawed patient admission systems,5 and for failing to ensure staff were adequately trained.6 In Bull v Devon Area Health Authority7 the English Court of Appeal held the Health Authority liable for injury caused to a newborn baby where a hospital emergency communication system had broken down. It is likely Irish courts would see as negligent a failure to adequately regulate issues such as patient handover and management of records that result in harm.

In short, a protocol such as that introduced by the Mater Hospital would not only help to prevent injuries arising from administrative errors but assist with the defence of claims should they arise