Ward / location
Handover type
Care setting
Target 90% · Compliance uses Yes / No responses only
Handover episodes
60
0 excluded
Overall compliance
78%
Target 90%
Structured framework used
71.7%
SBAR or local framework
Safety concerns
6
Handover-related concerns recorded
Criterion-level compliance
Percentage documented, by audit criterion (target line at 90%).
Compliance over time
Weekly overall compliance with median line.
Compliance by ward / location
- Frailty Unit84.3% (n=8)
- Respiratory Ward82.7% (n=9)
- Acute Medical Unit76.7% (n=13)
- Emergency Department76% (n=15)
- Surgical Ward 675.5% (n=11)
- Same-Day Emergency Care73.3% (n=4)
Compliance by handover type
- ED to specialty handover83.9% (n=6)
- Escalation handover83.8% (n=5)
- Shift-to-shift medical handover83.6% (n=5)
- SDEC to inpatient team handover81.1% (n=2)
- Hospital at night handover79.5% (n=6)
- ED to AMU handover78.6% (n=6)
- Ward-to-ward transfer handover77.1% (n=6)
- Out-of-hours handover76.3% (n=4)
- Shift-to-shift nursing handover75.5% (n=11)
- Weekend handover75.5% (n=2)
- Specialty referral handover75.5% (n=2)
- Critical care outreach handover71.4% (n=3)
- AMU to ward handover56% (n=2)
Compliance by care setting
- Same-day emergency care87.2% (n=3)
- Emergency department82.9% (n=7)
- Hospital at night82.3% (n=5)
- Critical care outreach78.9% (n=9)
- Inpatient surgical ward78.2% (n=9)
- Acute medical unit77.7% (n=8)
- Frailty unit75.8% (n=5)
- Outpatient / ambulatory area74.8% (n=6)
- Inpatient medical ward70.8% (n=6)
- Specialty ward68.6% (n=2)
Compliance by handover format
- Electronic handover system86.1% (n=6)
- Structured template81.1% (n=7)
- EPR note80.2% (n=7)
- Task management system79.7% (n=6)
- Email / secure message where locally permitted79.6% (n=9)
- Paper handover sheet75.3% (n=3)
- SBAR / local structured framework74.7% (n=10)
- Hybrid73.9% (n=6)
- Verbal handover with documented note70.4% (n=6)
Interpretation
Generated from the current filtered data.
60 handover episodes were reviewed against 27 audit criteria for Clinical Handover Audit at Demo Site — Main Hospital. Overall documented compliance was 78% against a local target of 90%. A structured handover framework was documented in 71.7% of episodes. 6 episodes were recorded with a handover-related safety concern.
- Overall compliance is below the local target of 90%, suggesting variation in how completely handover episodes are documented.
- Weekly compliance appears to be improving over the audit period.
- Current data suggests variation between locations, from 73.3% (Same-Day Emergency Care) to 84.3% (Frailty Unit).
- Some criteria could not be determined from the record, which may itself indicate unclear handover documentation.
Improvement opportunities
Suggested local improvement actions based on the lowest-performing criteria. Edit and plan these in the Improvement tab.
- Make task owner and expected next action mandatory fields in the handover template.
- Add a required urgency and review-timeframe prompt to each handover task.
- Enable closed-loop acknowledgement in the electronic handover system for urgent handovers.
- Add a structured pending-investigations field to transfer and shift handovers.
- Prompt clinicians to restate treatment escalation, DNACPR or ReSPECT status at handover.
- Standardise use of SBAR or the local structured handover framework across all clinical areas.
- Review handover-related safety concerns through the departmental governance meeting and incident learning process.
Criterion detail
Documented / applicable responses per criterion.
| # | Criterion | Yes / n | % | Target |
|---|---|---|---|---|
| 1 | Handover type | 55 / 60 | 91.7% | 90% |
| 2 | Date and time | 57 / 60 | 95% | 90% |
| 3 | Receiving team | 54 / 59 | 91.5% | 90% |
| 4 | Patient location | 57 / 59 | 96.6% | 90% |
| 5 | Responsible team | 56 / 59 | 94.9% | 90% |
| 6 | Responsible senior | 40 / 55 | 72.7% | 90% |
| 7 | Current situation | 54 / 58 | 93.1% | 90% |
| 8 | Background | 56 / 60 | 93.3% | 90% |
| 9 | Diagnosis / problem list | 53 / 60 | 88.3% | 90% |
| 10 | Current assessment | 50 / 58 | 86.2% | 90% |
| 11 | Priority / urgency | 40 / 60 | 66.7% | 90% |
| 12 | Deterioration risk | 42 / 58 | 72.4% | 90% |
| 13 | Escalation plan | 41 / 55 | 74.5% | 90% |
| 14 | Treatment escalation status | 27 / 53 | 50.9% | 90% |
| 15 | Pending results | 33 / 56 | 58.9% | 90% |
| 16 | Outstanding tasks | 51 / 57 | 89.5% | 90% |
| 17 | Task owner | 38 / 60 | 63.3% | 90% |
| 18 | Expected next step | 48 / 58 | 82.8% | 90% |
| 19 | Deadline / review time | 31 / 54 | 57.4% | 90% |
| 20 | Contingency plan | 35 / 55 | 63.6% | 90% |
| 21 | Medication / allergy risk | 38 / 50 | 76% | 90% |
| 22 | Infection / safeguarding / capacity risk | 40 / 56 | 71.4% | 90% |
| 23 | Patient / family communication | 43 / 55 | 78.2% | 90% |
| 24 | Closed-loop confirmation | 28 / 56 | 50% | 90% |
| 25 | Reason for incomplete handover | 33 / 47 | 70.2% | 90% |
| 26 | Clear enough to continue care | 44 / 59 | 74.6% | 90% |
| 27 | Safety concern escalated | 50 / 54 | 92.6% | 100% |
Missing / undetermined data
Criteria recorded as "Unable to determine".
- Outstanding tasks3
- Current situation2
- Current assessment2
- Expected next step2
- Receiving team1
- Patient location1
- Responsible team1
- Closed-loop confirmation1
- Clear enough to continue care1