Physiotherapist Handover Reflection: ERA

Experience

Before a long weekend, I handed over my caseload to a colleague covering the ward. One patient had a new, temporary restriction on weight-bearing following a procedure, agreed with the medical team late the previous day. I mentioned it verbally in a rushed corridor handover, but it was not yet reflected in the therapy notes, which still described the earlier mobility plan. Over the weekend, the covering therapist - reasonably relying on the written record - began progressing the patient's mobility. A nurse who remembered the restriction queried it, the session was stopped, and the patient came to no harm. The near miss was reported and reviewed.

Reflection

My immediate reaction was frustration that a verbal handover had not been enough - but that framing had it backwards. A rushed corridor conversation before a weekend is close to the least reliable channel available, and I had used it for the single most safety-critical item on my caseload. The written record, which is what any covering clinician will actually consult, said the opposite of what I had said aloud. My colleague did nothing wrong; the system I left behind was misleading. I also reflected on why the notes were out of date: I had deferred the documentation because the change came late in the day, treating paperwork as an end-of-task chore rather than as the handover itself. That mental model - notes as admin, speech as communication - is exactly what this incident disproved.

Action

I now update the written mobility status before leaving the ward whenever a restriction changes, treating documentation as the primary handover channel and speech as the supplement. For planned absences, I have started using a brief structured written handover for complex patients - highest-risk items first - rather than relying on conversation. I raised the near miss at our team meeting, and we agreed a shared rule: any change to weight-bearing status is documented and flagged at the time it is agreed, whoever is present. I will check with the team in a couple of months whether the rule is holding in practice.