How to Improve Patient Handoff Quality for Ensuring Patient Safety: A Systematic Review


Patient handoff is defined as a transfer and acceptance of responsibility for patient care that is achieved through effective communication. Communication breakdown in handoff procedures can lead to serious impacts in the patient’s care, inappropriate treatment, and potential harm to the patient. The aim of this systematic review is to know barriers in handoff process and find strategies to improve patient handoff quality for ensuring patient safety. The current study is systemic review with PRISMA method, retrieved from online databases such as ProQuest and PubMed using keywords ‘patient handoff’ OR ‘patient handover’ AND ‘patient safety’. The period of the study that has been reviewed is three years backwards. Based on this review,
potential barriers that can lead to handoff failure are lack of standardized handoff tool, lack of chances for face-to-face communication and the ability to interactive discussion, and lack of staff training and handoff supervision. Several improvement strategies to increase patient handoff quality based on this review are: implementation of standardized verbal and written handoff protocols, face-to-face interaction with
active discussion opportunities, minimal interruptions, accurate and up-to-date information with critical issues highlighted, staff education and training, handoff process supervision, leadership and regulation support. Improvements or impacts on patient safety were only stated in three journals. Barriers in handoff process must be addressed to find recommendation for handoff process improvement. By addressing barriers, patient handoff quality can be increased by several improvement strategies. Further studies are needed to prove the impact of effective patient handoff in reducing sentinel and adverse events.

Keywords: patient handoff, patient safety, handoff barrier

[1] World Health Organization (WHO). (2007). Communication during patient handovers. Patient Safety Solutions, vol. 1, no. 3, pp. 1–4.

[2] Cook, R., Christ, C., Rivera, A. J., et al. (2014). Opportunities for Process improvements in patient handoffs. Proceedings of the Institution of Mechanical Engineers.

[3] Kear, T. M. (2016). Patient handoffs: What they are and how they contribute to patient safety. Nephrology Nursing Journal, vol. 43, no. 4, pp. 339–342.

[4] Kear, T. M. (2016). Continuing nursing education. Patient handoffs in nephrology nurse practice settings: A safety study. Nephrology Nursing Journal, vol. 43, no. 5, pp. 379–400.

[5] Halm, M. A. (2013). Nursing handoffs: Ensuring safe passage for patients. American Journal of Critical Care, vol. 22, no. 2, pp. 158–162.

[6] Saleem, A. M., Paulus, J. K., Vassiliou, M. C., et al. (2015). Initial assessment of patient handoff in accredited general surgery residency programs in the United States and Canada: A cross-sectional survey. Canadian Journal of Surgery, vol. 58, no. 4. pp. 269–277.

[7] Petrovic, M. A., et al. (2015). The perioperative handoff protocol: Evaluating impacts on handoff defects and provider satisfaction in adult perianesthesia care units. Journal of Clinical Anesthesia, vol. 27, no. 2, pp. 111–119.

[8] Graham, K. L., Marcantonio, E. R., Huang, G. C., et al. (2013). Effect of a Systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. Journal of General Internal Medicine, no. 2, pp. 986–993.

[9] Abraham, J., Kannampallil, T., Patel, B., et al. (2012). Ensuring patient safety in care transitions: An empirical evaluation of a Handoff Intervention Tool. Annual Symposium Proceedings, vol. 2012, pp. 17–26.

[10] Solan, L. G., et al. (2014). Multidisciplinary handoffs improve perceptions of communication. Journal of the American Academy of Pediatrics.

[11] Pukenas, E. W., Dodson, G., Edward, R. D., et al. (2014). Simulation-based education with deliberate practice may improve intraoperative handoff skills: A pilot study. Journal of Clinical Anesthesia, vol. 26, no. 7, pp. 530–538.

[12] The Joint Commission. (2010). Advancing effective communication, cultural competence, and patient- and family-centered care: A roadmap for hospitals. Organization, p. 94.

[13] Starmer, A. J., et al. (2014). Changes in medical errors after implementation of a handoff program. The New England Journal of Medicine, vol. 371, no. 19, pp. 1803– 1812.