Nursing handoffs: A systematic review of the literature

American Journal of Nursing

Volumn 110, Issue 4, 2010, Pages 24-34

  Riesenberg, Lee Ann ^a,b   Leisch, Jessica ^a   Cunningham, Janet M ^a  

^a CHRISTIANA CARE HEALTH SYSTEM   (United States)

^b THOMAS JEFFERSON UNIVERSITY   (United States)

Author keywords

Hand off; Handoff; Handover; Shift report; Sign out; Signout

Indexed keywords

CLINICAL COMPETENCE; EDUCATION; EVIDENCE BASED NURSING; HUMAN; INTERPERSONAL COMMUNICATION; MEDICAL EDUCATION; METHODOLOGY; NURSING ASSESSMENT; NURSING EVALUATION RESEARCH; NURSING STAFF; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PATIENT CARE PLANNING; PSYCHOLOGICAL ASPECT; PUBLIC RELATIONS; QUALITATIVE RESEARCH; QUALITY CONTROL; REVIEW; STANDARD; TIME MANAGEMENT; UNITED STATES; WORKLOAD;

BENCHMARKING; CLINICAL COMPETENCE; COMMUNICATION; CONTINUITY OF PATIENT CARE; EVIDENCE-BASED NURSING; HUMANS; INTERPROFESSIONAL RELATIONS; NURSING ASSESSMENT; NURSING EVALUATION RESEARCH; NURSING STAFF; PATIENT CARE PLANNING; QUALITATIVE RESEARCH; RESEARCH DESIGN; TEACHING ROUNDS; TIME MANAGEMENT; UNITED STATES; WORKLOAD;

EID: 77950262787     PISSN: 0002936X     EISSN: None     Source Type: Journal    
DOI: 10.1097/01.NAJ.0000370154.79857.09     Document Type: Review

References (119)

1. The Joint Commission. National patient safety goals. Hand-off communications: standardized approach [NPSG.02.05.01]. 2008. http://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards/ 09-FAQs/NPSG/Communication/NPSG.02.05.01/hand-off-communications.htm.
2. Yob MO. Communication issues: a potential source of liability for nurses. Focus Crit Care 1988;15(2):78-79
3. Wilson RM, et al. The Quality in Australian Health Care Study. Med J Aust 1995;163(9):458-471
4. Croteau R. JCAHO comments on handoff requirement. OR Manager 2005;21(8):8.
5. Coiera E. When conversation is better than computation. J Am Med Inform Assoc 2000;7(3):277-286
6. Donchin Y, et al. A look into the nature and causes of human errors in the intensive care unit. 1995. Qual Saf Health Care 2003;12(2):143-7; discussion 7-8.
7. Coiera EW, et al. Communication loads on clinical staff in the emergency department. Med J Aust 2002;176(9):415-418
8. Payne S, et al. Interactions between nurses during handovers in elderly care. J Adv Nurs 2000;32(2):277-285
9. Volpp KG, Grande D. Residents' suggestions for reducing errors in teaching hospitals. N Engl J Med 2003;348(9):851-855
10. Dowding D. Examining the effects that manipulating information given in the change of shift report has on nurses' care planning ability. J Adv Nurs 2001;33(6):836-846
11. Pothier D, et al. Pilot study to show the loss of important data in nursing handover. Br J Nurs 2005;14(20):1090-1093
12. Ebright PR, et al. Themes surrounding novice nurse near-miss and adverse-event situations. J Nurs Adm 2004; 34(11):531-538
13. Agency for Healthcare Research and Quality. Hospital survey on patient safety culture: 2009 comparative database report. Rockville, MD; 2009 Mar. AHRQ Publication No. 09-0030. http://www.ahrq.gov/qual/hospsurvey09/hospsurv091.pdf.
14. Bernstam EV, et al. Reasons for after-hours calls by hospital floor nurses to on-call physicians. Jt Comm J Qual Patient Saf 2007;33(6):342-349
15. The Joint Commission. National patient safety goals: 2006 critical access hospital and hospital national patient safety goals. 2006. http://www. jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06-npsg-cah.htm.
16. The Joint Commission. Accreditation program: hospital. National patient safety goals. Oakbrook Terrace, IL; 2008. http://www.jointcommission.org/NR/ rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/HAP-NPSG.pdf.
17. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52(6):377-384
18. Deeks JJ, et al. Evaluating non-randomised intervention studies. Health Technol Assess 2003;7(27):iii-x, 1-173.
19. West S, et al. Systems to rate the strength of scientific evidence: evidence report/technology assessment number 47. Rockville, MD: Agency for Healthcare Research and Quality; 2002 Apr. AHRQ Publication No. 02-E016. Evidence report/technology assessment; http://www.ncbi.nlm.nih.gov/bookshelf/br. fcgi?book=hserta&part=A73054.
20. Riesenberg LA, et al. Residents' and attending physicians' handoffs: a systematic review of the literature. Acad Med 2009;84(12):1775-1787
21. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res 2005;15(9):1277-1288
22. Danis D, et al. Improving patient safety by standardizing handoff communications. Phoenix: 2007 NACNS national conference (National Association of Clinical Nurse Specialists) 2007.
23. Earhart A, Mangino RR. Patient handoffs: more than a buzz word. Changing a culture. Phoenix: 2007 NACNS national conference (National Association of Clinical Nurse Specialists) 2007.
24. Ellis D, et al. Back to the bedside: patient safety and handoff report. Phoenix: 2007 NACNS national conference (National Association of Clinical Nurse Specialists) 2007.
25. Johnson L, et al. Standardizing handoff communication using voice technology. Phoenix: 2007 NACNS national conference (National Association of Clinical Nurse Specialists) 2007.
26. Meliones J, et al. Improving patient safety through standardization of the handoff process for postoperative pediatric cardiothoracic patients. Phoenix: 2007 NACNS national conference (National Association of Clinical Nurse Specialists) 2007.
27. [no authors listed] JCAHO to look closely at patient handoffs. Healthcare Benchmarks Qual Improv 2005;12(12):143-144
28. [no authors listed] JCAHO's 2006 National Patient Safety Goals: handoffs are biggest challenge. Hosp Peer Rev 2005;30(7):89-93.
29. [no authors listed] Focus on five. Strategies to improve hand-off communication: implementing a process to resolve questions. Joint Commission Perspectives on Patient Safety 2005;5(7):11.
30. [no authors listed] The SBAR technique: improves communication, enhances patient safety. Joint Commission Perspectives on Patient Safety 2005;5(2):1-2, 8.
31. [no authors listed] Are dangerous errors occurring during change of shift? Use these strategies. ED Nursing 2005;8(12):133-136
32. [no authors listed] Stop 'handoff' errors when patients leave the ED. ED Nursing 2005;9(1):6-8.
33. [no authors listed] Are handoffs too 'automatic'? QI experts fear errors could rise. Healthcare Benchmarks Qual Improv 2006;13(1):1-4.
34. [no authors listed] Computer system helps nurses in care delivery. Healthcare Benchmarks Qual Improv 2006;13(3):28-30.
35. [no authors listed] Improving handoff communications: meeting national patient safety goal 2E. Joint Commission Perspectives on Patient Safety 2006;6(8):9-10, 15.
36. [no authors listed] A nutty idea for patient handoffs. Briefings on Patient Safety 2006:5-7.
37. [no authors listed] Frequently asked SBAR questions. Briefings on Patient Safety 2006:4-5.
38. [no authors listed] Measure understanding during handoffs. Briefings on Patient Safety 2006:8-9.
39. [no authors listed] Staff trainer. What's wrong with this hand-off? Briefings on Patient Safety 2006:9, 12.
40. [no authors listed] Patients at this hospital have a 'ticket to ride': handoff problem addressed with form. Case Management Advisor 2006;17(10):116-117
41. [no authors listed] Patient handoffs don't have to be high risk. RN 2006;69(8):20hfl.
42. [no authors listed] Safety guidelines: JCAHO sets standards for patient handoffs. Nursing 2006;36(3):35.
43. [no authors listed] AORN patient hand-off tool kit now available. AORN J 2007;85(6):1251.
44. [no authors listed] AORN offers handoff toolkit. OR Manager 2007;23(6):32.
45. [no authors listed] SBAR techniques help EDs comply with handoff regs. ED Manag 2007;19(11):suppl 3-4.
46. [no authors listed] SBAR for students. Nurs Educ Perspect 2007;28(6):306.
47. [no authors listed] Pass the baton or NUTS for safer handoff. Healthcare Risk Management 2007;29(10):115-117
48. Adamski P. Implement a handoff communications approach. Nurs Manage 2007;38(1):10, 12.
49. Barbera ML. Giving report: how to sidestep common pitfalls. Nursing 1994;24(9):41.
50. Bolger AM, Asghari F. Shift reports: using nursing diagnosis. Nurs Manage 1987;18(10):17.
51. Boynton B. Structured communication for hand offs: a shift toward collaboration with senders and receivers of critical information. Nurse Leader 2007;5(4):18-20.
52. Cox SS. Taping report: tips to record by. Nursing 1994;24(3):64.
53. Gregory Crum BS. Standardizing hand-off processes. AORN J 2006;84(6):1059-1061
54. Dracup K, Morris PE. Passing the torch: the challenge of handoffs. Am J Crit Care 2008;17(2):95-97
55. Elm J. Improving labor and delivery shift report. AWHONN Lifelines 2004;8(1):54-59
56. Federwisch A. Passing the baton: bedside shift report ensures quality handoff. Nurseweek (California) 2007;20(21):14.
57. Groah L. Hand offs-a link to improving patient safety. AORN J 2006;83(1):227-230
58. Groah L. Tips for introducing SBAR in the OR. OR Manager 2006;22(4):12.
59. Hansten R. Streamline change-of-shift report. Nurs Manage 2003;34(8):58-59
60. Hemmila D. Talking the talk: hospitals use SBAR to standardize communication. Nurs Spectr (N Engl Ed) 2006;10(18):22-23
61. Hilton L. How to handle handoffs without dropping the ball. Nurs Spectr (Midwestern Ed) 2004;5(8):12.
62. Hohenhaus SM, et al. Enhancing patient safety during hand-offs: standardized communication and teamwork using the 'SBAR' method. Am J Nurs 2006;106(8):72A-72B, 72D.
63. Kilpack V, Dobson-Brassard S. Intershift report: oral communication using the nursing process. J Neurosci Nurs 1987;19(5):266-270
64. Malestic SL. A quick guide to verbal reports. RN 2003;66(2):47-49
65. Mathias JM. A SHARED tool strengthens handoffs. OR Manager 2006;22(4):15.
66. Mathias JM. Passing the baton for smooth handoffs. OR Manager 2006;22(4):13.
67. McLaughlin E, et al. Get an A+ on end-of-shift report. Nursing 2004;34(6):hn8-hn10.
68. Mizerany PJ. Avoid shift change disasters: standardized handoffs defuse potential medical errors. Nurseweek (South Central) 2007;14(10):40.
69. Mosher C, Bontomasi R. How to improve your shift report. Am J Nurs 1996;96(8):32-34
70. Odom-Forren J. Accurate patient handoffs: imperative for patient safety. J Perianesth Nurs 2007;22(4):233-234
71. Pope BB, et al. Raising the SBAR: how better communication improves patient outcomes. Nursing 2007;38(3):41-43
72. Ramdayal I. For smoother shift changes, try walking rounds. RN 1990;53(9):19-23.
73. Richard JA. Walking rounds: a step in the right direction. Nursing 1989;19(6):63-64
74. Runy LA. Patient handoffs. Hosp Health Netw 2008;82(5):7 p following 40, 2.
75. Sandlin D. Improving patient safety by implementing a standardized and consistent approach to hand-off communication. J Perianesth Nurs 2007;22(4):289-292
76. Schroeder SJ. Picking up the PACE: a new template for shift report. Nursing 2006;36(10):22-23
77. Sibbald RG, Ayello EA. From the experts. SBAR for wound care communication: 20-second enablers for practice. Adv Skin Wound Care 2007;20(3):135-136
78. Simpson KR. Handling handoffs safely. MCN Am J Matern Child Nurs 2005;30(2):152.
79. Speas J. Bolster staff relations with shift report. Nurs Manage 2006;37(10):82-83
80. Sullivan EE. Hand-off communication. J Perianesth Nurs 2007;22(4):275-279
81. Thielman DE. Report: how to say it all in a few words. RN 1987;50(6):15-17
82. Wise D. The positives and negatives of handover. Contemp Nurse 1994;3(3):143-144
83. Young P, et al. Implementing changes in critical care shift report. Dimens Crit Care Nurs 1988;7(6):374-380
84. Yurkovich E, Smyer T. Shift report: a time for learning. J Nurs Educ 1998;37(9):401-403
85. Guido GW. Legal commentary: shift reports. Dimens Crit Care Nurs 1988;7(6):380.
86. Guise JM, Lowe NK. Do you speak SBAR? J Obstet Gynecol Neonatal Nurs 2006;35(3):313-314
87. Hohenhaus SM. An informal discussion of emergency nurses' current clinical practice: what's new and what works. "Handoffs" during ED patient transport within the institution. J Emerg Nurs 2005;31(6):567-568
88. Kiecker R. Handoff templates improve patient safety [letter]. Nursing 2006;36(12):8.
89. Mason DJ. Shift to shift: reclaiming patient 'hand-offs.' Am J Nurs 2004;104(9):11.
90. Powell SK. SBAR-it's not just another communication tool. Prof Case Manag 2007;12(4):195-196
91. Anthony MK, Preuss G. Models of care: the influence of nurse communication on patient safety. Nurs Econ 2002;20(5):209-15, 248.
92. Hays MM. The phenomenal shift report: a paradox. J Nurses Staff Dev 2003;19(1):25-33.
93. Patterson ES, et al. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care 2004;16(2):125-132
94. Priest CS, Holmberg SK. A new model for the mental health nursing change of shift report. J Psychosoc Nurs Ment Health Serv 2000;38(8):36-43.
95. Strople B, Ottani P. Can technology improve intershift report? What the research reveals. J Prof Nurs 2006;22(3):197-204.
96. Anderson CD, Mangino RR. Nurse shift report: who says you can't talk in front of the patient? Nurs Admin Q 2006;30(2):112-122
97. Baldwin L, McGinnis C. A computer-generated shift report. Nurs Manage 1994;25(9):61-64
98. Barbera ML, et al. A silent report. Nurs Manage 1998;29(6):66-67
99. Bolanos R. Bedside briefings: Miami Children's Hospital handoffs happen with patients included. Nurs Spectr (Fla Ed) 2008;18(2):22-23
100. Bosek MS, Fugate K. Intershift report: a quality improvement project. Medsurg Nurs 1994;3(2):128-132
101. Brown Lazzara PA. Make your best better with a reporting system. Nurs Manage 2004;35(8):48A-48B, 48D.
102. Fraser LE, et al. Patient care plans for intershift report. J Pediatr Nurs 1991;6(5):310-316
103. Haig KM, et al. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 2006;32(3):167-175
104. Hamilton P, et al. SBAR and nurse-physician communication: pilot testing an educational intervention. Nurs Admin Q 2006;30(3):295-299
105. Hays MM. An exploratory study of supportive communication during shift report. South Online J Nurs Res 2002;3(3):1-14.
106. Hays MM, Weinert C. A dramaturgical analysis of shift report patterns with cost implications: a case study. Nurs Econ 2006;24(5):253-62, 27.
107. Kalisch BJ, et al. PI tool patches broken communication. Nurs Manage 2007;38(4):16, 18.
108. Keenan G, et al. HANDS: A revitalized technology supported care planning method to improve nursing handoffs. Stud Health Technol Inform 2006;122:580-584
109. Mikos K. Monitoring handoffs for standardization. Nurs Manage 2007;38(12):16-20.
110. Monahan ML, et al. Change of shift report: a time for communication with patients. Nurs Manage 1988;19(2):80.
111. Reiley PJ, Stengrevics SS. Change-of-shift report: put it in writing! Nurs Manage 1989;20(9):54-56
112. Richard JA. Congruence between intershift reports and patients' actual conditions. Image J Nurs Sch 1988;20(1):4-6.
113. Shendell-Falik N, et al. Enhancing patient safety: improving the patient handoff process through appreciative inquiry. J Nurs Adm 2007;37(2):95-104.
114. Sidlow R, Katz-Sidlow RJ. Using a computerized sign-out system to improve physician-nurse communication. Jt Comm J Qual Patient Saf 2006;32(1):32-36
115. Wilson MJ. A template for safe and concise handovers. Medsurg Nurs 2007;16(3):201-6, 200.
116. Davidoff F, Batalden P. Toward stronger evidence on quality improvement. Draft publication guidelines: the beginning of a consensus project. Qual Saf Health Care 2005;14(5):319-325
117. Winters BD, et al. Rapid response teams-walk, don't run. JAMA 2006;296(13):1645-1647
118. SQUIRE: Standards for Quality Improvement Reporting Excellence. SQUIRE guidelines checklist 2008. http://www.squire-statement.org/assets/pdfs/SQUIRE- guidelines-table.pdf.
119. Stevens DP. Why new guidelines for reporting improvement research? And why now? Qual Saf Health Care 2005;14(5):314.