Doctors' handovers in hospitals: A literature review

BMJ Quality and Safety

Volumn 20, Issue 2, 2011, Pages 128-133

  Raduma Tomàs, Michelle A ^a   Flin, Rhona ^a   Yule, Steven ^a   Williams, David ^b  

^a UNIVERSITY OF ABERDEEN   (United Kingdom)

^b BEAUMONT HOSPITAL   (Ireland)

Author keywords

[No Author keywords available]

Indexed keywords

EMBASE; HOSPITAL; HUMAN; MEDICAL EDUCATION; MEDICAL PRACTICE; MEDLINE; PHYSICIAN; REVIEW; SKILL;

CONTINUITY OF PATIENT CARE; HUMANS; PATIENT TRANSFER; PHYSICIANS;

EID: 79953768389     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs.2009.034389     Document Type: Review

References (64)

1. National Patient Safety Agency. Safe Handover, Safe Patients: Guidance on Clinical Handover for Clinicians and Managers. London: BMA, 2004.
2. Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ 2000;320:791-4. (Pubitemid 30179436)
3. Apker J, Mallak LA, Gibson SC. Communicating in the 'gray zone': perceptions about emergency physician-hospitalist handoffs and patient safety. Acad Emerg Med 2007;14:884-94. (Pubitemid 47432753)
4. Department of Energy. The Public Inquiry into the Piper Alpha Disaster. Vols 1 and 2. Cm 1310 London: HMSO, 1990.
5. CSB: US Chemical Safety and Hazard Investigation Board. The report of the BPUS refineries independent safety review panel. 2007. http://www.csb.gov/ completed-investigations/docs/ Baker-panel-report.pdf (accessed 5 Dec 2008).
6. Joint Commission National Patient Safety Solutions. 2009. http://www.jointcommission.org/PatientSafety/Solutions/ (accessed 15 Jan 2009).
7. Patterson ES, Roth EM, Woods DD, et al. Handoff strategies in settings with high consequences for failure: lessons for healthcare operations. Int J Qual Health Care 2004;16:125-32. (Pubitemid 38489473)
8. Hoffman J. CRICO's handoff-related malpractice cases. In: LaValley D, ed. Reducing Risk During Handoffs. Forum, 2007;25:1-21.
9. Petersen LA, Brennan TA, O'Neil AC, et al. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 1994;121:866-72.
10. Thakore S, Morrison W. A survey of the perceived quality of patient handover by ambulance staff in the resuscitation room. Emerg Med J 2001;18:293-6. (Pubitemid 34070936)
11. Sorra J, Famolaro T, Dyer N, et al. Agency for Healthcare Quality and Research. Hospital Survey on Patient Safety Culture: 2008 Comparative database report. http://www.ahrq.gov/qual/ hospsurvey08 (accessed 28 Apr 2008).
12. Wong MC, Yee KC, Turner P. Clinical Handover Literature Review. eHealth Services Research Group. Australia: University of Tasmania, 2008.
13. Kerr MP. A qualitative study of shift handover practice and function from a socio-technical perspective. J Adv Nurs 2002;37:125-34.
14. Lally S. An investigation into the functions of nurses' communication at the inter-shift handover. J Nurs Manag 1999;7:29-36.
15. Lamond D. The information content of the nurse change of shift report: A comparative study. J Adv Nurs 2000;31:794-804.
16. Sexton A, Chan C, Elliott M, et al. Nursing handovers: do we really need them? J Nurs Manag 2004;12:37-42. (Pubitemid 38175733)
17. Australian Medical Association Limited. Safe handover: Safe patients. Guidance on clinical handover for clinicians and managers. 2006. http://www.ama.com.au/node/4064 (accessed 30 Sep 2007).
18. Royal College of Physicians. The Interface Between Acute General Medicine and Critical Care. Report of a Working Party. London: RCP, 2002.
19. Arora VM, Johnson J, Lovinger D, et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 2005;14:401-7. (Pubitemid 41820063)
20. Flanagan JC. The critical incident technique. Psychol Bull 1954;51:327-59.
21. Lawrence RH, Tomolo AM, Garlisi AP, et al. Conceptualizing handovers strategies at change of shift in the emergency department: a grounded theory study. BMC Health Serv Res 2008;8:256.
22. Borowitz SM, Waggoner-Fountain LA, Bass EJ, et al. Adequacy of information transferred at resident sign-out (in hospital handover of care): a prospective survey. Qual Saf Health Care 2008;17:6-10. (Pubitemid 351262947)
23. Bomba D, Prakash R. A description of handover processes in an Australian public hospital. Aust Health Rev 2005;29:68-79.
24. Tokode M, Barthelmes L, O'Riordan B. Near-misses and missed opportunities: poor patient handover in general surgery. Bull Roy Coll Surg England 2008;90:96-8.
25. McCann L, McHardy K, Child S. Passing the buck: clinical handovers at a New Zealand tertiary hospital. N Z Med J 2007;120:56-65.
26. Laxmisan A, Hakimzada F, Sayan OR, et al. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Int J Med Inform 2007;76:801-11. (Pubitemid 47575951)
27. Vidyarthi AR, Arora VM, Schnipper JL, et al. Managing discontinuity in academic medical centres: strategies for a safe and effective resident sign-out. J Hosp Med 2006;1:257-66.
28. Horwitz LI, Krumholz HM, Green ML, et al. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med 2006;166:1173-7. (Pubitemid 43877624)
29. Horwitz LI, Moin T, Krumholz HM, et al. Consequences of inadequate sign-out for patient care. Arch Intern Med 2008;168:1755-60.
30. Horwitz LI, Krumholz HM, Wang L, et al. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care 2009;18:248-55.
31. Fassett MJ, Hannan TJ, Robertson IK, et al. A national survey of medical morning handover report in Australian hospitals. Med J Aust 2007;187:164-5. (Pubitemid 47307669)
32. Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: A survey of medical and surgical house staff. Jt Comm J Qual Patient Saf 2008;34:563-70.
33. Sinha M, Shriki J, Salness R, et al. Need for standardized sign-out in the emergency department: a survey of emergency medicine residency and paediatric emergency medicine fellowship program directors. Acad Emerg Med 2007;14:192-6. (Pubitemid 46157189)
34. Ye K, McD Taylor D, Knott JC, et al. Handover in the emergency department: deficiencies and adverse effects. Emerg Med Australas 2007;19:433-41.
35. Flanagan ME, Patterson ES, Frankel RM, et al. Evaluation of a physician informatics tool to improve patient handoffs. J Am Med Inform Assoc 2009;16:509-15.
36. Philibert I. Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. Qual Saf Health Care 2009;18:261-6.
37. Sharit J, McCane L, Thevenin DM, et al. Examining links between sign-out reporting during shift changeovers and patient management risks. Risk Anal 2008;28:969-81.
38. Alem L, Joseph M, Kethers S, et al. Information environments for supporting consistent registrar medical handover. HIM J 2008;37:9-25.
39. Yee KC, Wong MC, Turner P. Medical error management and the role of information technology - a new approach to investigating medical handover in acute care settings. Stud Health Technol Inform 2006;124:679-84.
40. Arora V, Kao J, Lovinger D, et al. Medication discrepancies in resident sign-outs and their potential to harm. J Gen Intern Med 2007;22:1751-5. (Pubitemid 350160350)
41. Wilson S, Galliers J, Fone J. Cognitive artefacts in support of medical shift handover: an in use, in situ evaluation. Int J Hum Comput Interact 2007;22:59-80.
42. Jeffcott SA, Ibrahim JE, Cameron PA. Resilience in healthcare and clinical handover. Qual Saf Health Care 2009;18:256-60.
43. Wears RL, Perry SJ, McFauks A. Dynamic changes in reliability and resilience in the emergency department. Proceedings of the Human Factors and Ergonomics Society 51st Annual Meeting. Baltimore, MD: 2007:612-16.
44. Iglehart K. Revisiting duty-hour limits - IOM recommendations for patient safety and resident education. N Engl J Med 2008;359:2633-5.
45. Cleland JA, Ross S, Miller SC, et al. 'There is a chain of Chinese whispers.': empirical data support the call to formally teach handover to pre-qualification doctors. Qual Saf Health Care 2009;18:267-71.
46. Horwitz LI, Moin T, Green ML. Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med 2007;22:1470-4. (Pubitemid 47476705)
47. Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 2006;32:167-75.
48. Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf 2006;32:646-55.
49. Stiles BM, Reece TB, Hedrick TL, et al. General surgery morning report: a competency-based conference that enhances patient care and resident education. Curr Surg 2006;63:385-90. (Pubitemid 44645009)
50. Fassett RG, Bollipo SJ. Morning report: an Australian experience. Med J Aust 2006;184:159-61.
51. Lee LH, Levine JA, Schultz HJ. Utility of a standardized sign-out card for new medical interns. J Gen Intern Med 1996;11:753-5. (Pubitemid 27009655)
52. Bhabra G, Mackeith S, Monteiro P, et al. An experimental comparison of handover methods. Ann R Coll Surg Engl 2007;89:298-300. (Pubitemid 46563967)
53. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004;13:85-90.
54. World Health Organization. Communication during patient handovers. Patient Safety Solutions 2007;1:1-4.
55. Parker J. Handovers in a changing health care climate. Aust Nurs J 1996;4:22-6.
56. Cheah L, Amott DH, Pollard J, et al. Electronic medical handover: towards safer medical care. Med J Aust 2005;183:369-72. (Pubitemid 41430839)
57. Johnson JK, Arora VM. Improving clinical handovers: creating local solutions for a global problem. Qual Saf Health Care 2009;18:244-5.
58. Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med 2005;80:1094-9. (Pubitemid 44366105)
59. Mays N, Pope C. Qualitative Research in Health Care. London: BMJ Publishing Group, 1996.
60. Riesenberg LA, Leitzsch J, Massucci JL. Residents' and attending physicians' handoffs: a systematic review of the literature. Acad Med 2009;84:1775-87.
61. 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;52:377-84. (Pubitemid 28438523)
62. Jeffcott SA, Evans SM, Cameron PA, et al. Improving measurement in clinical handover. Qual Saf Health Care 2009;18:272-6.
63. Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf 2010;36:52-61.
64. Shepherd A, Stammers RB. In: Wilson JR, Corlett N, eds. Evaluation of Human Work. 3rd edn. Boca Raton, FL: Taylor & Francis Group, 2005:129-56.