Background: Effective transfer of information relating to patient care is vital in healthcare. In the UK formal handover is an established and well reported process in the clinical setting but less so in transfusion laboratories. Blood transfusions occur within many hospital specialities and across clinical and laboratory staff shifts, making robust handover critical for safe practice. Failure to adequately transfer information relating to pending or ongoing provision of blood components during shift handover in the laboratory can have an adverse impact on patient care.
Aims: To identify transfusion errors where laboratory handover was considered a contributory factor.
Materials and methods: Serious adverse events and reactions reported to the UK haemovigilance scheme, Serious Hazards of Transfusion (SHOT), involving handover in the transfusion laboratory were reviewed for a 6-year period.
Results: Laboratory incidents involving handover were mainly associated with incorrect blood component transfused-specific requirements not met (IBCT-SRNM) and delays in provision of blood components transfusion, with 16.6% of these cases involving major haemorrhage situations. Handover was found to be insufficient in most cases, no handover was completed in 29.5% of cases, inadequate written handover accounted for 14.8% cases, and inadequate verbal for 5.7% of cases.
Discussion: Poor handover can lead to laboratory errors, particularly delays in provision of blood components. Embedding effective handover processes in the laboratory and including handover time within the shift working pattern, may help reduce errors and ensure continuity of care.
Conclusion: Handover should be considered a task that is built into laboratory routine practices, ensuring effective transfer of information and appropriate follow up actions are taken. SHOT have created a handover template which can be adopted in laboratories to formalise this process.
Keywords: communication; handover; laboratory.
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