The DOI matches its Crossref record; 58 of the 59 references it cites were found in a registry or an index.
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,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]
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A surgical safety checklist to reduce morbidity and mortality in a global population
Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A.-H. S., Dellinger, E. P., Herbosa, T., Joseph, S., Kibatala, P. L., Lapitan, M. C. M., et al. (2009) · New England Journal of Medicine · doi:10.1056/nejmsa0810119 · Cited by 5,688
Leonard, M. (2004) · BMJ Quality & Safety · doi:10.1136/qshc.2004.010033 · Cited by 2,346
Association Between Implementation of a Medical Team Training Program and Surgical Mortality
Neily, J. B., Mills, P. D., Young‐Xu, Y., Carney, B. T., West, P., Berger, D. H., Mazzia, L. M., Paull, D. E., & Bagian, J. P. (2010) · JAMA · doi:10.1001/jama.2010.1506 · Cited by 1,039
Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients
Greenberg, C. C., Regenbogen, S. E., Studdert, D. M., Lipsitz, S. R., Rogers, S. O., Zinner, M. J., & Gawande, A. A. (2007) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2007.01.010 · Cited by 856
Surgical team behaviors and patient outcomes
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Incidents relating to the intra-hospital transfer of critically ill patients
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Arora, V. M. (2005) · BMJ Quality & Safety · doi:10.1136/qshc.2005.015107 · Cited by 607
Improving Patient Care: The Implementation of Change in Clinical Practice
Grol, R. P. T. M., Wensing, M., Eccles, M., Davis, D., & Wensign, M. (2005) · Cited by 553
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Catchpole, K. C., de Leval, M. R., McEwan, A. I., Pigott, N., Elliott, M. J., McQuillan, A., MacDonald, C., & Goldman, A. P. (2007) · Pediatric Anesthesia · doi:10.1111/j.1460-9592.2006.02239.x · Cited by 516
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1 of the 59 references couldn’t be matched to a known paper.
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- Joy, 2011, Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit., Pediatr Crit Care Med, 12, 304, 10.1097/PCC.0b013e3181fe25a1 · DOI
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Interprofessional Care and Teamwork in the ICU
Donovan, A. L., Aldrich, J. M., Gross, K., Barchas, D., Thornton, K. C., Schell-Chaple, H. M., Gropper, M. A., & Lipshutz, A. K. M. (2018) · Critical Care Medicine · doi:10.1097/ccm.0000000000003067 · Cited by 321
Brindle, M. E., McDiarmid, C., Short, K., Miller, K. E., MacRobie, A., Lam, J., Brockel, M. A., Raval, M. V., Howlett, A. A., Lee, K., et al. (2020) · World Journal of Surgery · doi:10.1007/s00268-020-05530-1 · Cited by 178
Human factors in preventing complications in anaesthesia: a systematic review
Jones, C. P. L., Fawkner-Corbett, J., Groom, P., Morton, B., Lister, C., & Mercer, S. J. (2018) · Anaesthesia · doi:10.1111/anae.14136 · Cited by 151
Parshuram, C. S., Amaral, A. C. K. B., Ferguson, N. D., Baker, G. R., Etchells, E. E., Flintoft, V., Granton, J., Lingard, L., Kirpalani, H., Mehta, S., et al. (2015) · Canadian Medical Association Journal · doi:10.1503/cmaj.140752 · Cited by 104
Clinical Handover and Handoff in Healthcare: A Systematic Review of Systematic Reviews
Desmedt, M., Ulenaers, D., Grosemans, J., Hellings, J., & Bergs, J. (2021) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzaa170 · Cited by 102
Metadata
- 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 › Nursing › Leadership and Management › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
- Social Sciences › Decision Sciences › Management Science and Operations Research › 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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