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Implementation of a new tool to improve the efficacy and safety of surgical handovers
International Journal of Surgery 13 (2015) 189e192
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Before and after study
Implementation of a new tool to improve the efficacy and safety of surgical handovers E.L. Blower*, T. MacCarrick, H. Forster, P.A. Sutton, D. Vimalachandran Department of General Surgery, Countess of Chester Hospital NHS Foundation Trust, Chester, England, United Kingdom
h i g h l i g h t s A more detailed handover template resulted in a significant improvement in practice. This is likely to have direct implications for patient safety and standard of care. Simple inexpensive measures such as this are vital to maximise NHS efficiency. Trainees informally acknowledged the quality of the tool. We recommend that all institutions undertake a critical review of their handover.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 March 2014 Received in revised form 4 September 2014 Accepted 18 November 2014 Available online 27 November 2014
Aims: Compliance with European working time regulations in surgical practice has resulted in an increase in the number of clinicians caring for individual patients and subsequently an increase in the frequency of handovers. In 2007, the Royal College of Surgeons of England produced guidelines on the minimum data-set for ‘safe handover’. This audit examined compliance with these guidelines before and after adopting a more detailed electronic handover ‘template’ with the intention of improving handover quality and patient safety. Methods: Pre-existing surgical ‘take’ electronic handover sheets were reviewed daily for two weeks to assess compliance with published guidance. A new proforma was introduced, training delivered and compliance re-audited. c2 analysis was performed to determine statistical significance. Results: The handovers of 118 patients were audited before, and 114 after, the implementation of the new proforma. Name and responsible consultant were recorded in all cases. Age (52% vs.85%,p¼<0.01), location (77% vs.95%,p¼<0.01), admission date (0% vs.39%,p¼<0.01), medical history (82% vs.94%,p ¼ 0.01), diagnosis (55% vs.93%,p¼<0.01) and management plan (81% vs.97%,p¼<0.01) showed a statistically significant improvement with the new proforma. Presenting complaint (93% vs.98%) and investigation (90% vs.90%) data remained good. Review frequency (5%vs.11%) and outstanding tasks (21%vs.27%) were poorly documented. Conclusions: Significant improvement was seen in the completeness of information handed-over following the introduction of the new proforma with likely positive implications for patient safety and standard of care. Opportunity for improvement still remains however, and more specific focussed tuition for trainees is required. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Handover Quality improvement Patient safety European working time regulations Education
1. Introduction The European Working Time Regulations (EWTR) were introduced into modern surgical practice for doctors in training in 2009, leading to widespread changes in work patterns [1]. EWTR have
* Corresponding author. Countess of Chester Hospital NHS Foundation Trust, Liverpool Road, Chester CH2 1UL, England, United Kingdom. E-mail address: [email protected] (E.L. Blower). http://dx.doi.org/10.1016/j.ijsu.2014.11.019 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
resulted in an increase in shift work with a greater number of clinicians caring for each patient during their hospital stay and subsequently more handovers [2]. There is good evidence to support the fact that the transfer of patient care to the oncoming clinical team is an extremely high risk step in a patient's hospital journey [3]. Effective handover protects patient safety, provides continuity of care and avoids errors [4,5]. Handovers also offer an excellent opportunity for training and clinical review [6]. The Royal College of Surgeons of England (RCSE) introduced good practice principle guidelines in 2007, suggesting a minimum
190
E.L. Blower et al. / International Journal of Surgery 13 (2015) 189e192
data-set for a safe handover [7] (Table 1). The aim of this study was to examine the compliance of the general surgical handover with the RCSE guidelines at our institution both before and after adopting a detailed electronic handover template with the intention of improving handover quality and patient safety. 2. Methods A proforma was devised to record the frequency with which RCSE recommended elements were included in patient handover [7]. The pre-existing general surgical ‘take’ electronic handover sheet (Fig. 1) was reviewed for compliance with these guidelines daily for 2 weeks in October 2012. A more detailed electronic handover template was subsequently introduced within the department and all trainees received specific instruction on its use (Fig. 2). The new proforma was again reviewed daily over a 2 week period to assess compliance with RCSE guidelines [7]. In an effort to reduce bias, both review periods were undertaken during weeks when the auditing team were not on duty. Statistical significance was assessed using the c2 test. 3. Results On critical review, the pre-existing handover record was limited and consisted of only 6 fields. It did not specify the exact details required in each field. The implemented profroma contained 14 fields, and detailed each of the factors identified in the RCSE minimum data set. The handovers of 118 patients were audited before, and 114 after, the implementation of the new proforma. The results are summarised in Table 2 and represented graphically in Fig. 3. The patient's name was recorded and the responsible consultant clearly identified in all cases. Age, location, admission date, medical history, diagnosis and management showed a statistically significant improvement with the new proforma. Presenting complaint and investigation data remained good. Review frequency and outstanding tasks were poorly documented. 4. Discussion By introducing a more detailed electronic handover template to reflect the RCSE guidance, we have demonstrated a significant improvement in our handover practice. Whilst an electronic handover using a system that requires input of free text entry is associated with occasional deficiencies, those with prompts or predefined fields have been shown to maximise information transfer [8]. Crucially, there is agreement within the literature that electronic handovers are better than verbal or paper-based handovers which are still commonplace in many institutions [9e11]. Electronic handovers offer a permanent record of the information passed on to the oncoming team and are therefore a legal
Table 1 Royal College of Surgeons of England guidelines on the minimum data-set required for a safe surgical handover. Minimum requirements for handover
Also include
Patient name and age Date of admission Location (ward and bed) Responsible consultant surgeon Current diagnosis Results of significant or pending investigations
Patient condition Urgency/frequency of review Management plan Resuscitation plan Consultant contact details Other issues and outstanding tasks
document which can prove vital when investigating untoward events. Electronic handovers also negate the possibility of lost paper documents and the subsequent data protection concerns that may arise. Most importantly within this study was the improvement seen in the documentation of diagnosis and management plan. This is likely to have direct implications for patient safety and the standard and continuity of care. Whilst this was not formally assessed in our study, there is robust evidence to suggest that accurate handover is fundamental to patient safety [7,12]. Interestingly, Ryan et al. showed that the introduction of ‘electronic signout’ handover with predefined fields in accordance with the RCSE guidelines, actually reduced the median length of stay from five to four days (p ¼ 0.047) [13]. Whilst our study did not directly address this, reduction in length of stay has benefits beyond improved patient care, including patient experience and cost-effectiveness. In the current era of financial constraints within the NHS, simple inexpensive measures such as improving handover quality are vital to maximise efficiency. Handover must also be considered as an educational event as it gives trainees the opportunity to present and discuss patients, refine their working diagnosis and revise their management plan in light of the discussion with senior colleagues [12]. This opportunity should be exploited, especially in the context of reduced working hours brought about by EWTR. Handover also provides an opportunity to develop skills of communication, presentation, problemsolving and leadership, as well as helping in the formation and organisation of the team [12]. In our study, even areas of good compliance showed an improvement with the implementation of the new proforma and crucially it did not appear to be detrimental to any areas of the handover process. Trainees informally acknowledged the quality of the tool, from which we assume acceptance into practice. Further work remains in ensuring a completely reliable and robust handover, with particular reference to the required frequency of review and outstanding tasks. This improvement could be made by placing additional emphasis on the importance of the handover process, for example by providing increased training at the undergraduate and early postgraduate level. Consideration could also be given to adding a separate column for the required frequency of review. We expect that individuals are less likely to leave a field entirely blank, although this would be at the expense of making the handover tool more cumbersome. Our current handover tool could be improved even further by creating a direct link with the patient's electronic medical record to ensure that the working diagnosis and management plan is available to all staff involved in the patient's care and updated daily. There are potential limitations to our study. Most notably information was only deemed to have been handed over if it was documented on the template. Sessions were not witnessed and therefore there is no additional record of any information handed over verbally. Our justification for this is that without a written record to refer to, information may not be retained and therefore lost, particularly in the midst of a busy shift. We believe an electronic record to be the most effective way of ensuring the information required by the incoming team is readily available to them for the duration of their shift [9]. In addition there are other elements of the RCSE guidance not considered here. They suggest that all patients should be aware of their responsible clinician, that all patients under the care of a team should be co-located, that clinical actions are clearly documented in the patient's notes and are traceable back to the doctor concerned, that sufficient time is set aside for handover during working hours in an appropriate environment and that handover is ideally bleep-free. The RCSE again
E.L. Blower et al. / International Journal of Surgery 13 (2015) 189e192
191
Fig. 1. Pre-existing handover template.
Fig. 2. New handover template.
Table 2 Summary of results: Metrics are displayed in each column with the percentage of cases in which they were recorded both pre and post intervention of the new handover proforma.
Old proforma (n ¼ 118) New proforma (n ¼ 114) p-value (chi-squared test)
Age
Location Date of admission
Presenting complaint
Past medical history
Diagnosis Investigation Management Frequency of review
Outstanding tasks
52%
77%
0%
93%
82%
55%
90%
81%
5%
21%
85%
95%
39%
98%
94%
93%
90%
97%
11%
27%
p ¼ 0.12
p ¼ 0.01
P 0.01
p ¼ 0.89
p 0.01
p ¼ 0.13
p ¼ 0.36
p 0.01 p 0.01 p 0.01
Fig. 3. Percentage of cases in which each element of the required data set were recorded both pre and post intervention of the new handover proforma.
highlight the importance of confidentiality and storing patient information sensitively but also accessibly [7]. The simple measure of introducing a more detailed electronic handover proforma has lead to a statistically significant improvement in the efficacy of the handover process within our institution. Complete and relevant handovers have been shown to improve patient safety, increase the standard and continuity of care, reduce the hospital length of stay and increase the educational value of the handover process. In light of this we recommend that all institutions undertake a critical review of their handover arrangements and consider the implementation of a similar tool. Ethical approval None required. Sources of funding None. Author contribution E Blower e study design, data collection, data analysis, writing T MacCarrick e data collection.
H Forster e data collection. P Sutton e study design, writing. D Vimalachandran e oversaw project. Conflicts of interest None. References [1] http://www.nhsemployers.org/PlanningYourWorkforce/MedicalWorkforce/ EWTD/Pages/EWTD.aspx. (Last accessed 14.02.14.). [2] Re-shaping Surgical Services: Principles for Change, The Royal College of Surgeons of England, January 2013. [3] NHS Services, Seven Days a Week Forum. (http://www.england.nhs.uk/wpcontent/uploads/2013/12/evidence-base.pdf e (Last accessed 14.03.14.). [4] S.M. Borowitz, L.A. Waggoner-Fountain, E.J. Bass, R.M. Sledd, Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey, Qual. Saf. Healthc. 17 (1) (2008) 6e10. [5] M.C. Wong, K.C. Yee, P. Turner, A Structured Evidence-based Literature Review Regarding the Effectiveness of Improvement Interventions in Clinical Handover, Australian Commission on Safety and Quality in Healthcare, 2008. [6] Safe Handover: Safe Patients. Guidelines on Clinical Handover for Clinicians and Managers, British Medical Association, August 2004. [7] Safe Handover: Guidance from the Working Time Directive Working Party, Royal College of Surgeons of England, March 2007. [8] L.P. Cheah, D.H. Amott, J. Pollard, D.A.K. Watters, Electronic medical handover: towards safer medical care, Med. J. Aust. 183 (7) (2005) 369e372.
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[9] N. Ferran, A. Metcalf, D. O'Doherty, Standardised profromas improve patient handover: audit of trauma practice, Patient Saf. Surg. 2 (1) (2008) 24e28. [10] D.A. Raptis, C. Fernandes, W. Chua, P.B. Boulos, Electronic software significantly improves quality of handover in a London teaching hospital, Health Informatics J. 15 (3) (2009) 191e198. [11] P. Stimpson, A. Joshi, R. Oakley, R. Simo, Surgical Handover: aspiring easy access without breach of patient confidentiality, Clin. Otolaryngol. 34 (1) (2009) 83e84.
[12] S. Rehman, S. Mehmood, J. Ahmed, M.H. Razzaq, S. Khan, E.P. Perry, Surgical handover in an era of reduced working hours: an audit of current practice, J. Coll. Physicians Surg. Pak. 22 (6) (2012) 385e388. [13] S. Ryan, J.M. O'Riordan, S. Tierney, K.C. Conlon, P.F. Ridgeway, Impact of new electronic handover system in surgery, Int. J. Surg. 9 (1) (2011) 217e220.
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Before and after study
Implementation of a new tool to improve the efficacy and safety of surgical handovers E.L. Blower*, T. MacCarrick, H. Forster, P.A. Sutton, D. Vimalachandran Department of General Surgery, Countess of Chester Hospital NHS Foundation Trust, Chester, England, United Kingdom
h i g h l i g h t s A more detailed handover template resulted in a significant improvement in practice. This is likely to have direct implications for patient safety and standard of care. Simple inexpensive measures such as this are vital to maximise NHS efficiency. Trainees informally acknowledged the quality of the tool. We recommend that all institutions undertake a critical review of their handover.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 March 2014 Received in revised form 4 September 2014 Accepted 18 November 2014 Available online 27 November 2014
Aims: Compliance with European working time regulations in surgical practice has resulted in an increase in the number of clinicians caring for individual patients and subsequently an increase in the frequency of handovers. In 2007, the Royal College of Surgeons of England produced guidelines on the minimum data-set for ‘safe handover’. This audit examined compliance with these guidelines before and after adopting a more detailed electronic handover ‘template’ with the intention of improving handover quality and patient safety. Methods: Pre-existing surgical ‘take’ electronic handover sheets were reviewed daily for two weeks to assess compliance with published guidance. A new proforma was introduced, training delivered and compliance re-audited. c2 analysis was performed to determine statistical significance. Results: The handovers of 118 patients were audited before, and 114 after, the implementation of the new proforma. Name and responsible consultant were recorded in all cases. Age (52% vs.85%,p¼<0.01), location (77% vs.95%,p¼<0.01), admission date (0% vs.39%,p¼<0.01), medical history (82% vs.94%,p ¼ 0.01), diagnosis (55% vs.93%,p¼<0.01) and management plan (81% vs.97%,p¼<0.01) showed a statistically significant improvement with the new proforma. Presenting complaint (93% vs.98%) and investigation (90% vs.90%) data remained good. Review frequency (5%vs.11%) and outstanding tasks (21%vs.27%) were poorly documented. Conclusions: Significant improvement was seen in the completeness of information handed-over following the introduction of the new proforma with likely positive implications for patient safety and standard of care. Opportunity for improvement still remains however, and more specific focussed tuition for trainees is required. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Handover Quality improvement Patient safety European working time regulations Education
1. Introduction The European Working Time Regulations (EWTR) were introduced into modern surgical practice for doctors in training in 2009, leading to widespread changes in work patterns [1]. EWTR have
* Corresponding author. Countess of Chester Hospital NHS Foundation Trust, Liverpool Road, Chester CH2 1UL, England, United Kingdom. E-mail address: [email protected] (E.L. Blower). http://dx.doi.org/10.1016/j.ijsu.2014.11.019 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
resulted in an increase in shift work with a greater number of clinicians caring for each patient during their hospital stay and subsequently more handovers [2]. There is good evidence to support the fact that the transfer of patient care to the oncoming clinical team is an extremely high risk step in a patient's hospital journey [3]. Effective handover protects patient safety, provides continuity of care and avoids errors [4,5]. Handovers also offer an excellent opportunity for training and clinical review [6]. The Royal College of Surgeons of England (RCSE) introduced good practice principle guidelines in 2007, suggesting a minimum
190
E.L. Blower et al. / International Journal of Surgery 13 (2015) 189e192
data-set for a safe handover [7] (Table 1). The aim of this study was to examine the compliance of the general surgical handover with the RCSE guidelines at our institution both before and after adopting a detailed electronic handover template with the intention of improving handover quality and patient safety. 2. Methods A proforma was devised to record the frequency with which RCSE recommended elements were included in patient handover [7]. The pre-existing general surgical ‘take’ electronic handover sheet (Fig. 1) was reviewed for compliance with these guidelines daily for 2 weeks in October 2012. A more detailed electronic handover template was subsequently introduced within the department and all trainees received specific instruction on its use (Fig. 2). The new proforma was again reviewed daily over a 2 week period to assess compliance with RCSE guidelines [7]. In an effort to reduce bias, both review periods were undertaken during weeks when the auditing team were not on duty. Statistical significance was assessed using the c2 test. 3. Results On critical review, the pre-existing handover record was limited and consisted of only 6 fields. It did not specify the exact details required in each field. The implemented profroma contained 14 fields, and detailed each of the factors identified in the RCSE minimum data set. The handovers of 118 patients were audited before, and 114 after, the implementation of the new proforma. The results are summarised in Table 2 and represented graphically in Fig. 3. The patient's name was recorded and the responsible consultant clearly identified in all cases. Age, location, admission date, medical history, diagnosis and management showed a statistically significant improvement with the new proforma. Presenting complaint and investigation data remained good. Review frequency and outstanding tasks were poorly documented. 4. Discussion By introducing a more detailed electronic handover template to reflect the RCSE guidance, we have demonstrated a significant improvement in our handover practice. Whilst an electronic handover using a system that requires input of free text entry is associated with occasional deficiencies, those with prompts or predefined fields have been shown to maximise information transfer [8]. Crucially, there is agreement within the literature that electronic handovers are better than verbal or paper-based handovers which are still commonplace in many institutions [9e11]. Electronic handovers offer a permanent record of the information passed on to the oncoming team and are therefore a legal
Table 1 Royal College of Surgeons of England guidelines on the minimum data-set required for a safe surgical handover. Minimum requirements for handover
Also include
Patient name and age Date of admission Location (ward and bed) Responsible consultant surgeon Current diagnosis Results of significant or pending investigations
Patient condition Urgency/frequency of review Management plan Resuscitation plan Consultant contact details Other issues and outstanding tasks
document which can prove vital when investigating untoward events. Electronic handovers also negate the possibility of lost paper documents and the subsequent data protection concerns that may arise. Most importantly within this study was the improvement seen in the documentation of diagnosis and management plan. This is likely to have direct implications for patient safety and the standard and continuity of care. Whilst this was not formally assessed in our study, there is robust evidence to suggest that accurate handover is fundamental to patient safety [7,12]. Interestingly, Ryan et al. showed that the introduction of ‘electronic signout’ handover with predefined fields in accordance with the RCSE guidelines, actually reduced the median length of stay from five to four days (p ¼ 0.047) [13]. Whilst our study did not directly address this, reduction in length of stay has benefits beyond improved patient care, including patient experience and cost-effectiveness. In the current era of financial constraints within the NHS, simple inexpensive measures such as improving handover quality are vital to maximise efficiency. Handover must also be considered as an educational event as it gives trainees the opportunity to present and discuss patients, refine their working diagnosis and revise their management plan in light of the discussion with senior colleagues [12]. This opportunity should be exploited, especially in the context of reduced working hours brought about by EWTR. Handover also provides an opportunity to develop skills of communication, presentation, problemsolving and leadership, as well as helping in the formation and organisation of the team [12]. In our study, even areas of good compliance showed an improvement with the implementation of the new proforma and crucially it did not appear to be detrimental to any areas of the handover process. Trainees informally acknowledged the quality of the tool, from which we assume acceptance into practice. Further work remains in ensuring a completely reliable and robust handover, with particular reference to the required frequency of review and outstanding tasks. This improvement could be made by placing additional emphasis on the importance of the handover process, for example by providing increased training at the undergraduate and early postgraduate level. Consideration could also be given to adding a separate column for the required frequency of review. We expect that individuals are less likely to leave a field entirely blank, although this would be at the expense of making the handover tool more cumbersome. Our current handover tool could be improved even further by creating a direct link with the patient's electronic medical record to ensure that the working diagnosis and management plan is available to all staff involved in the patient's care and updated daily. There are potential limitations to our study. Most notably information was only deemed to have been handed over if it was documented on the template. Sessions were not witnessed and therefore there is no additional record of any information handed over verbally. Our justification for this is that without a written record to refer to, information may not be retained and therefore lost, particularly in the midst of a busy shift. We believe an electronic record to be the most effective way of ensuring the information required by the incoming team is readily available to them for the duration of their shift [9]. In addition there are other elements of the RCSE guidance not considered here. They suggest that all patients should be aware of their responsible clinician, that all patients under the care of a team should be co-located, that clinical actions are clearly documented in the patient's notes and are traceable back to the doctor concerned, that sufficient time is set aside for handover during working hours in an appropriate environment and that handover is ideally bleep-free. The RCSE again
E.L. Blower et al. / International Journal of Surgery 13 (2015) 189e192
191
Fig. 1. Pre-existing handover template.
Fig. 2. New handover template.
Table 2 Summary of results: Metrics are displayed in each column with the percentage of cases in which they were recorded both pre and post intervention of the new handover proforma.
Old proforma (n ¼ 118) New proforma (n ¼ 114) p-value (chi-squared test)
Age
Location Date of admission
Presenting complaint
Past medical history
Diagnosis Investigation Management Frequency of review
Outstanding tasks
52%
77%
0%
93%
82%
55%
90%
81%
5%
21%
85%
95%
39%
98%
94%
93%
90%
97%
11%
27%
p ¼ 0.12
p ¼ 0.01
P 0.01
p ¼ 0.89
p 0.01
p ¼ 0.13
p ¼ 0.36
p 0.01 p 0.01 p 0.01
Fig. 3. Percentage of cases in which each element of the required data set were recorded both pre and post intervention of the new handover proforma.
highlight the importance of confidentiality and storing patient information sensitively but also accessibly [7]. The simple measure of introducing a more detailed electronic handover proforma has lead to a statistically significant improvement in the efficacy of the handover process within our institution. Complete and relevant handovers have been shown to improve patient safety, increase the standard and continuity of care, reduce the hospital length of stay and increase the educational value of the handover process. In light of this we recommend that all institutions undertake a critical review of their handover arrangements and consider the implementation of a similar tool. Ethical approval None required. Sources of funding None. Author contribution E Blower e study design, data collection, data analysis, writing T MacCarrick e data collection.
H Forster e data collection. P Sutton e study design, writing. D Vimalachandran e oversaw project. Conflicts of interest None. References [1] http://www.nhsemployers.org/PlanningYourWorkforce/MedicalWorkforce/ EWTD/Pages/EWTD.aspx. (Last accessed 14.02.14.). [2] Re-shaping Surgical Services: Principles for Change, The Royal College of Surgeons of England, January 2013. [3] NHS Services, Seven Days a Week Forum. (http://www.england.nhs.uk/wpcontent/uploads/2013/12/evidence-base.pdf e (Last accessed 14.03.14.). [4] S.M. Borowitz, L.A. Waggoner-Fountain, E.J. Bass, R.M. Sledd, Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey, Qual. Saf. Healthc. 17 (1) (2008) 6e10. [5] M.C. Wong, K.C. Yee, P. Turner, A Structured Evidence-based Literature Review Regarding the Effectiveness of Improvement Interventions in Clinical Handover, Australian Commission on Safety and Quality in Healthcare, 2008. [6] Safe Handover: Safe Patients. Guidelines on Clinical Handover for Clinicians and Managers, British Medical Association, August 2004. [7] Safe Handover: Guidance from the Working Time Directive Working Party, Royal College of Surgeons of England, March 2007. [8] L.P. Cheah, D.H. Amott, J. Pollard, D.A.K. Watters, Electronic medical handover: towards safer medical care, Med. J. Aust. 183 (7) (2005) 369e372.
192
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[9] N. Ferran, A. Metcalf, D. O'Doherty, Standardised profromas improve patient handover: audit of trauma practice, Patient Saf. Surg. 2 (1) (2008) 24e28. [10] D.A. Raptis, C. Fernandes, W. Chua, P.B. Boulos, Electronic software significantly improves quality of handover in a London teaching hospital, Health Informatics J. 15 (3) (2009) 191e198. [11] P. Stimpson, A. Joshi, R. Oakley, R. Simo, Surgical Handover: aspiring easy access without breach of patient confidentiality, Clin. Otolaryngol. 34 (1) (2009) 83e84.
[12] S. Rehman, S. Mehmood, J. Ahmed, M.H. Razzaq, S. Khan, E.P. Perry, Surgical handover in an era of reduced working hours: an audit of current practice, J. Coll. Physicians Surg. Pak. 22 (6) (2012) 385e388. [13] S. Ryan, J.M. O'Riordan, S. Tierney, K.C. Conlon, P.F. Ridgeway, Impact of new electronic handover system in surgery, Int. J. Surg. 9 (1) (2011) 217e220.