Effective handover communication: An overview of research and improvement efforts

Best Practice and Research: Clinical Anaesthesiology

Volumn 25, Issue 2, 2011, Pages 181-191

  Manser, Tanja ^a   Foster, Simon ^b  

^a UNIVERSITY OF FRIBOURG   (Switzerland)

^b Eidgenössische Technische Hochschule Zürich   (Switzerland)

Author keywords

communication; handover; quality improvement; safety

Indexed keywords

CLINICAL PRACTICE; ELECTRONIC MEDICAL RECORD; HEALTH CARE PERSONNEL; HEALTH CARE QUALITY; HUMAN; INTERPERSONAL COMMUNICATION; OUTCOME ASSESSMENT; PATIENT CARE; PATIENT SAFETY; POSTOPERATIVE ANALGESIA; PRIORITY JOURNAL; REVIEW;

COMMUNICATION; CONTINUITY OF PATIENT CARE; HUMANS; PATIENT CARE TEAM; QUALITY OF HEALTH CARE;

EID: 79955836158     PISSN: 15216896     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.bpa.2011.02.006     Document Type: Review

References (92)

1. British Medical Association, National Patient Safety Agency, NHS Modernisation Agency. Safe handover: safe patients. Guidance on clinical handover for clinicians and managers [cited 2011 January 21]; Available online at: 2005 http://www.saferhealthcare.org.uk/IHI/Products/Publications/ safehandoversafepatients.htm2005.
2. High 5s. High 5s project action on patient safety [cited 2011 January 21]; Available online at: 2006 https://www.high5s.org/pub/Manual/ TrainingMaterials/High5sProjectOverviewFactSheet.pdf.2006.
3. Joint Commission on Accreditation of Healthcare Organisations. JCAHO National patient safety goals for 2007 [cited 2011 January 21]; Available online at: 2007 http://www.patientsafety.gov/TIPS/Docs/TIPS-JanFeb07.pdf.
4. Suresh G, Horbar JD, Plsek P et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics 2004; 113(6): 1609.
5. El-Dawlatly AA, Takrouri MS, Thalaj A et al. Critical incident reports in adults: an analytical study in a teaching hospital. Middle East Journal of Anesthesiology 2004; 17(6): 1045-1054. (Pubitemid 40091144)
6. Pronovost P, Thompson D, Holzmueller CG et al. Toward learning from patient safety reporting systems. Journal of Critical Care 2006; 21(4): 305-315. (Pubitemid 44908870)
7. Lingard L, Espin S, Whyte S et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Quality & Safety in Health Care 2004; 13(5): 330-334. (Pubitemid 39389393)
8. Wiegmann DA, ElBardissi AW, Dearani JA et al. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery 2007; 142(5): 658-665. (Pubitemid 350018854)
9. Catchpole KR, Giddings AE, Wilkinson M et al. Improving patient safety by identifying latent failures in successful operations. Surgery 2007; 142(1): 102-110. (Pubitemid 47049644)
10. Beach C. Lost in transition. AHRQ morbidity & mortality rounds on the web 2006.
11. Australian Institute of Health and Welfare and the Australian Commission on Safetyand Quality in Health Care. Sentinel events in australian public hospitals 2004-05. AIHW cat. no. HSE 51. Canberra: Australian Institute of Health and Welfare, 2007.
12. Greenberg CC, Regenbogen SE, Studdert DM et al. Patterns of communication breakdowns resulting in injury to surgical patients. Journal of the American College of Surgeons 2007; 204: 533-540.
13. 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. Quality & Safety in Health Care 2008; 17(1): 6-10. (Pubitemid 351262947)
14. Pezzolesi C, Schifano F, Pickles J et al. Clinical handover incident reporting in one UK general hospital. International Journal for Quality in Health Care 2010; 22(5): 396-401.
15. Patterson ES, Roth EM, Woods DD et al. Handoff strategies in settings with high consequences for failure: lessons for health care operations. International Journal for Quality in Health Care 2004; 16(2): 125-132. (Pubitemid 38489473)
16. Australian Council for Safety and Quality in Health Care. Clinical handover and patient safety literature review report [cited 2011 January 21]; Available online at: 2005 http://www.ihi.org/IHI/Topics/PatientSafety/ SafetyGeneral/Literature/ClinicalHandoverPtSafetyLitReviewReport.htm2005.
17. Committee on quality of health care in America. Crossing the quality chasm: a NEW health system for the 21st century. Washington, D.C.: National Academy Press, 2001.
18. Kalkman CJ. Handover in the perioperative care process. Current Opinion in Anaesthesiology 2010; 23(6): 749-753.
19. Strople B & Ottani P. Can technology improve intershift report? What the research reveals. Journal of Professional Nursing 2006; 22(3): 197-204. (Pubitemid 43852783)
20. Riesenberg LA, Leisch J & Cunningham JM. Nursing handoffs: a systematic review of the literature. The American Journal of Nursing 2010; 110(4): 24-34.
21. Messam K & Pettifer A. Understanding best practice within nurse intershift handover: what suits palliative care? International Journal of Palliative Nursing 2009; 15(4): 190-196.
22. Raduma-Tomas MA, Flin R, Yule S et al. Doctors' handovers in hospitals: a literature review. BMJ Quality and Safety 2011; doi:10.1136/bmjqs.2009.034389. Published Online First 5 January 2011.
23. Riesenberg LA, Leitzsch J, Massucci JL et al. Residents' and attending physicians' handoffs: a systematic review of the literature. Academic Medicine 2009; 84(12): 1775-1787.
24. Nagpal K, Arora S, Abboudi M et al. Postoperative handover: problems, pitfalls, and prevention of error. Annals of Surgery 2010; 252(1): 171-176.
25. Propp DA. Emergency care transitions. Academic Emergency Medicine 2003; 10(10): 1143.
26. Beach C, Croskerry P & Shapiro M. Profiles in patient safety: emergency care transitions. Academic emergency medicine 2003; 10(4): 364-367. (Pubitemid 36437795)
27. Catchpole KR, De Leval MR, McEwan A et al. Patient handover from surgery to intensive care: using formula 1 pit-stop and aviation models to improve safety and quality. Pediatric Anesthesia 2007; 17(5): 470-478. (Pubitemid 46633402)
28. McFetridge B, Gillespie M, Goode D et al. An exploration of the handover process of critically ill patients between nursing staff from the emergency department and the intensive care unit. Nursing in Critical Care 2007; 12(6): 261-269.
29. Jenkin A, Abelson-Mitchell N & Cooper S. Patient handover: time for a change? Accident and Emergency Nursing 2007; 15(3): 141-147.
30. Lawrence RH, Tomolo AM, Garlisi AP et al. Conceptualizing handover strategies at change of shift in the emergency department: a grounded theory study. BMC Health Services Research 2008; 8: 256.
31. Bomba DT & Prakash R. A description of handover processes in an Australian public hospital. Australian Health Review 2005; 29(1): 68-79.
32. Roughton VJ & Severs MP. The junior doctor handover: current practices and future expectations. Journal of the Royal College of Physicians of London 1996; 30(3): 213-214. (Pubitemid 126507006)
33. Horwitz LI, Meredith T, Schuur JD et al. Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Annals of Emergency Medicine 2009; 53(6): 701-710 e4.
34. Meissner A, Hasselhorn H-M, Estryn-Behar M et al. Nurses' perception of shift handovers in Europe: results from the European Nurses' early exit study. Journal of Advanced Nursing 2007; 57(5): 535-542.
35. Smith AF, Pope C, Goodwin D et al. Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room. British Journal of Anaesthesia 2008; 101(3): 332-337.
36. Parush A, Simoneau Y, Foster-Hunt T et al. The use of resources during shift hand-offs in a pediatric intensive care unit. In: Proceedings of the human factors and ergonomics society annual meeting. San Francisco: Human Factors and Ergonomics Society, 2010.
37. Gaba DM. Anaesthesiology as a model for patient safety in health care. British Medical Journal 2000; 320(7237): 785-788. (Pubitemid 30179434)
38. Horn E & Jacobi J. The critical care clinical pharmacist: evolution of an essential team member. Critical Care Medicine 2006; 34(3): S46-S51. (Pubitemid 43255751)
39. Smith AF & Mishra K. Interaction between anaesthetists, their patients, and the anaesthesia team. British Journal of Anaesthesia 2010; 105(1): 60-68.
40. Anwari JS. Quality of handover to the postanaesthesia care unit nurse. Anaesthesia 2002; 57(5): 484-500.
41. Nagpal K, Vats A, Ahmed K et al. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Annals of surgery 2010; 252(2): 402-407.
42. Patterson ES & Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Joint Commission Journal on Quality and Patient Safety 2010; 36(2): 52-61.
43. Cheung DS, Kelly JJ, Beach C et al. Improving handoffs in the emergency department. Annals of Emergency Medicine 2010; 55(2): 171-180.
44. Horwitz LI, Moin T, Krumholz HM et al. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Quality & Safety in Health Care 2009; 18(4): 248-255.
45. Arora V, Johnson J, Lovinger D et al. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Quality & Safety in Health Care 2005; 14(6): 401-407. (Pubitemid 41820063)
46. Lamond D. The information content of the nurse change of shift report: a comparative study. Journal of Advanced Nursing 2000; 31(4): 794-804.
47. Arora V, Kao J, Lovinger D et al. Medication discrepancies in resident sign-outs and their potential to harm. Journal of General Internal Medicine 2007; 22(12): 1751-1755. (Pubitemid 350160350)
48. Philibert I. Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. Quality & Safety in Health Care 2009; 18(4): 261-266.
49. Apker J, Mallak LA, Applegate 3rd EB et al. Exploring emergency physician-hospitalist handoff interactions: development of the handoff communication assessment. Annals of Emergency Medicine 2010; 55(2): 161-170.
50. Thakore S & Morrison W. A survey of the perceived quality of patient handover by ambulance staff in the resuscitation room. Emergency Medicine Journal 2001; 18(4): 293-296. (Pubitemid 34070936)
51. Manser T, Foster S, Gisin S et al. Assessing the quality of patient handoffs at care transitions. Quality & Safety in Health Care 2010; 19(6): 1-5.
52. Bhabra G, Mackeith S, Monteiro P et al. An experimental comparison of handover methods. Annals of the Royal College of Surgeons of England 2007; 89(3): 298-300.
53. Dowding D. Examining the effects that manipulating information given in the change of shift report has on nurses' care planning ability. Journal of Advanced Nursing 2001; 33(6): 836-846.
54. 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 prequalification doctors. Quality & Safety in Health Care 2009; 18(4): 267-271.
55. Horwitz LI, Krumholz HM, Green ML et al. Transfers of patient care between house staff on internal medicine wards: a national survey. Archives of Internal Medicine 2006; 166(11): 1173-1177. (Pubitemid 43877624)
56. Landucci D & Gipe BT. The art and science of the handoff: how hospitalists share data. The Hospitalist 1999; 3(1): 4.
57. American Society of Anesthesiologists Task Force on Postanesthetic Care. Practice Guidelines for Postanesthetic Care. Available online at: http://www.asahq.org/For-Members/Clinical-Information/Standards-Guidelines-and- Statements.aspx. 2009.
58. Association of Anaesthetists of Great Britain and Ireland. Immediate Postanaesthetic Recovery. Available online at: http://www.aagbi.org/ publications/guidelines/docs/postanaes02.pdf2002.
59. Horn J, Bell D & Moss E. Handover of responsibility for the anaesthetised patient - opinion and practice. Anaesthesia 2004; 59: 658-663. (Pubitemid 38997007)
60. Ye K, Taylor DM, Knott JC et al. Handover in the emergency department: deficiencies and adverse effects. Emergency Medicine Australasia 2007; 19(5): 433-441. (Pubitemid 47554194)
61. Berkenstadt H, Haviv Y, Tuval A et al. Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk. Chest 2008; 134(1): 158-162.
62. Talbot R & Bleetman A. Retention of information by emergency department staff at ambulance handover: do standardised approaches work? Emergency Medicine Journal 2007; 24(8): 539-542. (Pubitemid 47193720)
63. Riesenberg LA, Leitzsch J & Little BW. Systematic review of handoff mnemonics literature. American Journal of Medical Quality 2009; 24(3): 196-204.
64. Haig KM, Sutton S & Whittington J. SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety 2006; 32(3): 167-175.
65. Haynes AB, Weiser TG, Berry WR et al. A surgical safety checklist to reduce morbidity and mortality in a global population. The New England Journal of Medicine 2009; 360(5): 491-499.
66. Patterson ES. Structuring flexibility: the potential good, bad and ugly in standardisation of handovers. Quality & Safety in Health Care 2008; 17(1): 4-5. (Pubitemid 351262946)
67. Petersen LA, Orav EJ, Teich JM et al. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. The Joint Commission Journal on Quality Improvement 1998; 24(2): 77-87.
68. Pickering BW, Hurley K & Marsh B. Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover. Critical Care Medicine 2009; 37(11): 2905-2912.
69. Flanagan ME, Patterson ES, Frankel RM et al. Evaluation of a physician informatics tool to improve patient handoffs. Journal of the American Medical Informatics Association 2009; 16(4): 509-515.
70. Arora VM, Manjarrez E, Dressler DD et al. Hospitalist handoffs: a systematic review and task force recommendations. Journal of Hospital Medicine 2009; 4(7): 433-440.
71. Sharit J, McCane L, Thevenin DM et al. Examining links between sign-out reporting during shift changeovers and patient management risks. Risk Analysis 2008; 28(4): 969-981.
72. Van Eaton EG, Horvath KD, Lober WB et al. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. Journal of the American College of Surgeons 2005; 200(4): 538-545. (Pubitemid 40432321)
73. Jeffcott SA, Evans SM, Cameron PA et al. Improving measurement in clinical handover. Quality & Safety in Health Care 2009; 18(4): 272-276.
74. Yong G, Dent AW & Weiland TJ. Handover from paramedics: observations and emergency department clinician perceptions. Emergency Medicine Australasia 2008; 20(2): 149-155. (Pubitemid 351464709)
75. Hopkinson JB. The hidden benefit: the supportive function of the nursing handover for qualified nurses caring for dying people in hospital. Journal of Clinical Nursing 2002; 11(2): 168-175. (Pubitemid 41749802)
76. Bruce K & Suserud BO. The handover process and triage of ambulance-borne patients: the experiences of emergency nurses. Nursing in Critical Care 2005; 10(4): 201-209.
77. Evans SM, Murray A, Patrick I et al. Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members. Quality & safety in health care 2010; 19(6): e57.
78. Salerno SM, Arnett MV & Domanski JP. Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward. Teaching and Learning in Medicine 2009; 21(2): 121-126.
79. Philpin S. 'Handing over': transmission of information between nurses in an intensive therapy unit. Nursing in Critical Care 2006; 11(2): 86-93.
80. Yee KC, Wong MC & Turner P. "Hand me an ISOBAR": a pilot study of an evidence-based approach to improving shift-to-shift clinical handover. The Medical Journal of Australia 2009; 190(11 Suppl): S121-S124.
81. Evans SM, Murray A, Patrick I et al. Assessing clinical handover between paramedics and the trauma team. Injury 2010; 41(5): 460-464.
82. Payne S, Hardey M & Coleman P. Interactions between nurses during handovers in elderly care. Journal of advanced nursing. 2000; 32(2): 277-285.
83. Mazzocco K, Petitti DB, Fong KT et al. Surgical team behaviors and patient outcomes. American Journal of Surgery 2009; 197(5): 678-685.
84. Haggerty JL, Reid RJ, Freeman GK et al. Continuity of care: a multidisciplinary review. British Medical Journal 2003; 327: 1219-1221.
85. Freudenthal A & Pattynama PMT. What's in a surgeons mind? Learning for performing treatments and operating equipment. In Casciaro S & Gersak B (eds.). New technology frontiers in minimally invasive therapies. Lupiens Biomedical Publications, 2007, pp. 112-121.
86. Perry S. Transitions in care: studying safety in emergency department Signovers. Focus on Patient Safety 2004; 7(2): 1-3.
87. Clancy CM. Care transitions: a threat and an opportunity for patient safety. American Journal of Medical Quality 2006; 21(6): 415-417. (Pubitemid 44673176)
88. Patterson E, Woods D, Cook R et al. Collaborative cross-checking to enhance resilience. Cognition, Technology & Work 2007; 9: 155-162.
89. Jeffcott SA, Ibrahim JE & Cameron PA. Resilience in healthcare and clinical handover. Qual Saf Health Care 2009; 18(4): 256-260.
90. Harvey CM, Schuster RJ, Durso FT et al. Human factors of transition of care. In Carayon P (ed.). Handbook of human factors and ergonomics in health care and patient safety. Mahwah, NJ: Lawrence Erlbaum Associates, 2007, pp. 233-248.
91. Behara R, Wears RL, Perry S et al. A conceptual framework for studying the safety of transitions in emergency care. Advances in patient safety: from research to implementation [cited 2011 January 21]; Available online at: 2005 http://www.ahrq.gov/downloads/pub/advances/vol2/Behara.pdf2005.
92. Cabana MD, Rand CS, Powe NR et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. Journal of the American Medical Association 1999; 282(15): 1458-1465. (Pubitemid 29493800)