Can We Make Postoperative Patient Handovers Safer? A Systematic Review of the Literature
Open accessAbstract
Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.
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Incomplete or inaccurate handoffs are a source of subsequent medical errors and patient injury, particularly for patients undergoing major surgery.
“Incomplete or inaccurate handoffs are a source of subsequent medical errors and patient injury,1–3 particularly for patients undergoing major surgery.4–7”
From Potential uses of AI for perioperative nursing handoffs: a qualitative study (2023) · cites this paper as [4]
The Results and Conclusions (page not available) link poor postoperative handovers with adverse outcomes, but explicitly say that causality cannot be established. The review covers surgical patients generally; it does not establish that the risk is particular to patients undergoing major surgery. (LLM, conf=0.86)
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- Authors
- Segall, N., Bonifacio, A. S., Schroeder, R. A., Barbeito, A., Rogers, D., Thornlow, D. K., Emery, J., Kellum, S., Wright, M. C., & Mark, J. B.
- Affiliations
- Duke University (US)
- Durham VA Medical Center (US)
- Duke Medical Center (US)
- Trinity Health (US)
- Corresponding author
- Segall, Noa
- Schroeder, Rebecca A.
- Venue
- Anesthesia & Analgesia
- Published
- 2012-07
- Volume
- 115
- Issue
- 1
- Pages
- 102-115
- ISSN
- 0003-2999 (ISSN-L)
- PMC
- PMC6152818
- OpenAlex
- W2107099173
- Cited by
- 250
- References
- 59
- Citations by year
- 2026: 11 · 2025: 5 · 2024: 15 · 2023: 20 · 2022: 10 · 2021: 27 · 2020: 14 · 2019: 22 · 2018: 29 · 2017: 28 · 2016: 19 · 2015: 23 · 2014: 14 · 2013: 10 · 2012: 2
- FWCI
- 3.47
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Anesthesia & Analgesia (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Agency for Healthcare Research and Quality (K02HS015704)
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Health Professions › Emergency Medical Services › Healthcare Operations and Scheduling Optimization
- Keywords
- patient safety, communication errors, handover checklist, team communication, adverse events, information transmission
- MeSH terms
- Anesthesia Recovery Period, Clinical Protocols, Continuity of Patient Care, Humans, Intensive Care Units, Operating Rooms, Patient Care Team, Patient Transfer, Practice Patterns, Physicians', Postoperative Care, Practice Guidelines as Topic, Medical Errors, Guideline Adherence, Quality Indicators, Health Care, Interdisciplinary Communication, Checklist, Patient Safety
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