Short answer
Information is lost at handover in three situations:
- the outgoing shift has no time to prepare;
- the exchange is one-way;
- the incoming shift has no chance to check what it was told.
To find out where this happens in your organisation, ask the people on both sides about a recent handover that went wrong. Ask what was passed on, what was missing, how they found out and what it cost. Compare their accounts with the handover log, and report what each group described rather than a single cause.
What a good handover looks like
The HSE guidance on shift handover describes effective handover as three elements:
- preparation by the outgoing personnel;
- communication between outgoing and incoming personnel;
- cross-checking by the incoming personnel as they take responsibility.
It recommends that handovers be face-to-face and two-way, use both verbal and written communication, rest on what incoming staff need to know, and get as much time as necessary.
That gives a useful frame for an investigation. Information can be lost at any of the three stages, and each stage needs different evidence.
| Stage | How information is lost | Evidence to look for |
|---|---|---|
| Preparation | The outgoing shift is still working at changeover; the log is written in a hurry or not at all | Log timestamps, overtime records, accounts of the final hour |
| Exchange | It is one-way, written only, or done by someone who was not on the shift | Who hands over to whom, where, and for how long |
| Cross-check | Incoming staff cannot question or verify what they were told | Accounts of the first hour of the new shift; corrections logged later |
Ask about a specific handover
General questions about handover get general answers: "it's fine" or "communication is bad". Instead, ask about the last handover where something was missed.
Topics that work:
- How a handover normally runs on your shift, step by step.
- The last time you found out something important after the handover.
- How you found out, and what you had to do as a result.
- What the log or system showed, and what it left out.
- What would have to change for that not to happen again.
Ask both sides. Outgoing staff may say they recorded everything, while incoming staff say the record was unusable when they needed it. Both can be true.
Include the people between shifts
Handovers are not only between shifts. The HSE guidance includes handovers between shift and day workers, and between functions within a shift, such as operations and maintenance. Agency staff, floaters and people covering a gap often receive the least context. Invite them, and keep them as a separate group in the findings.
A fictional example: a hospital ward
A fictional hospital asks why medication timing errors cluster in the first two hours of the night shift on one ward. It writes this question: "How is information passed on at nursing handover on Ward 7, where does it get lost, and what does it cost patients and teams?"
Ten nurses and two healthcare assistants answer: five from days, five from nights, and the two assistants, who regularly cover. Their accounts:
- Six of the ten nurses describe the day shift still giving evening medication at 7.30 pm, which shortens the bedside handover.
- Four night nurses describe finding changes to medication timing in the electronic record that nobody mentioned verbally.
- Both cover staff say they receive the handover sheet but no verbal handover at all.
- Two day nurses disagree that handovers are shortened; both usually work on the quieter bay.
The ward manager compares the accounts with the electronic record's timestamps. Several timing changes were entered after 7 pm. The findings point to three possible changes:
- protect fifteen minutes for preparation;
- add a short verbal check of timing changes for each patient;
- give cover staff a handover of their own.
The interviews prove none of them. Each is a test with a measure attached.
Keep the investigation about the process
Handover problems are often blamed on individuals. A fair investigation asks about the conditions people work in. A finding about a named person needs that person's account and a proper process, not an interview summary. The HSE human factors introduction is a useful reminder that the way work is designed shapes behaviour. For frontline teams more broadly, see the frontline employee engagement guide and the guide to frontline manager know-how.
What to do with the findings
| Finding type | Example | Action |
|---|---|---|
| Preparation time | Outgoing staff still working at changeover | Protect a preparation window; check the rota overlap |
| One-way exchange | A written sheet only, with no questions | Add a short two-way check for high-risk items |
| Missing cross-check | Incoming staff cannot verify what they were told | Make a first-hour check part of the procedure |
| Excluded groups | Cover staff get no verbal handover | Name who hands over to them |
Record who owns each action, and when the same people will be asked again.
Where Lontra fits
Lontra lets you invite the people on both sides of the handover to a private conversation. They answer in their own time, on their phone, in their own time. Lontra asks about the last handover that went wrong and follows up on what they say. If someone shares a photo of a handover sheet or a screenshot of the record, Lontra reads it and asks about what it shows.
The findings show how many people described each problem, where day and night staff disagree, and what nobody could say, with the quotes behind each point. Deep Study can follow up with a colleague someone names, such as the person who covers the ward at weekends.
It does not replace your incident reporting, clinical governance or safety investigation processes, and it should not be used to investigate an individual.
Start with the handover people remember
The most useful evidence is the last handover that went wrong, described by the people on both sides. Ask about it while it is recent, compare it with the record, and change one thing you can measure.
Frequently asked questions
- Who should be interviewed about shift handover problems?
- Outgoing and incoming staff, cover and agency staff who receive handovers, and anyone who hands over between functions, such as maintenance. Keep each group separate in the findings.
- Can a written handover log replace a verbal handover?
- Written records help, but HSE guidance recommends handovers that are two-way and use both verbal and written communication, so the incoming person can ask questions and check what they were told.
- How do we know whether a handover change worked?
- Choose a measure before the change, such as errors in the first hours of a shift or corrections logged after handover, and ask the same people the same questions after a set period.