Structured Abstract

1. Background and Purpose

The Agency for Healthcare Research and Quality (AHRQ) Making Healthcare Safer (MHS) reports consolidate information for healthcare providers, health system administrators, researchers, and government agencies about patient safety practices (PSPs) that can improve patient safety across the healthcare system—from hospitals to primary care practices, long-term care facilities, and other healthcare settings. In spring 2023, AHRQ launched its fourth iteration of the MHS Report (MHS IV).

The topic of handoff protocols was identified as high priority for inclusion in the MHS IV reports using a modified Delphi technique by a Technical Expert Panel (TEP) that met in December 2022. The TEP included 15 experts in patient safety with representatives of governmental agencies, healthcare stakeholders, clinical specialists, experts in patient safety issues, and a patient/consumer perspective. See the MHS IV Prioritization Report for additional details. In the prioritization process, the MHS IV TEP defined the scope of handoffs to “intrahospital transitions.”

2. Methods

We followed rapid review processes of the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program.²¹ We registered the protocol for this rapid review in PROSPERO (registration number CRD42024576324).

For this rapid review, strategic adjustments were made to streamline traditional systematic review processes and deliver an evidence product in the allotted time. Adjustments included being as specific as possible about the questions, limiting the number of databases searched, modifying search strategies to focus on finding the most valuable studies (i.e., being flexible on sensitivity to increase the specificity of the search), and restricting the search to studies published in the last 10 years (2013 to June/July 2024) in English, and having each study assessed by a single reviewer. For this report, we used the artificial intelligence (AI) feature of DistillerSR (AI Classifier Manager) as a second reviewer at the title and abstract screening stage.

We searched for recent high quality systematic reviews as defined by the U.S. Preventive Services Task Force and relied primarily on the content of any such systematic reviews that were found. We did not perform an independent assessment of original studies cited in any such systematic review.

For a recent eligible systematic review, the primary reviewer used the criteria developed by the U.S. Preventive Services Task Force Methods Workgroup²² for assessing the quality of systematic reviews:

• Good—Recent relevant review with comprehensive sources and search strategies, explicit and relevant selection criteria, standard appraisal of included studies, and valid conclusions.
• Fair—Recent relevant review that is not clearly biased but lacks comprehensive sources and search strategies.
• Poor—Outdated, irrelevant, or biased review without systematic search for studies, explicit selection criteria, or standard appraisal of studies.

For Contextual Questions 1 (rationale), 2 (barriers and facilitators), and 3 (resources), we extracted information reported in the studies addressing the main Review Question. For contextual question 4, we searched publicly available patient safety toolkits developed by AHRQ or other organizations that could help to support implementation of the PSPs. To accomplish that task, we reviewed PSNet (https:/psnet.ahrq.gov) and AHRQ’s listing of patient safety related toolkits (https://www.ahrq.gov/tools/index.html?search_api_views_fulltext=&field_toolkit_topics=14170&sort_by=title&sort_order=ASC), and we included any toolkits mentioned in the studies we found for the Review Question. We identified toolkits without assessing or endorsing them.

The draft report will undergo a peer review process. The report will then be revised to address any comments before being finalized.

2.1. Eligibility Criteria

We searched for original studies and systematic reviews on the Review Question according to the inclusion and exclusion criteria presented in Table 1.

Table 1

Inclusion and Exclusion Criteria.

3. Evidence Base

3.1. Included Studies

Our search retrieved 789 unique titles and abstracts from which we reviewed 108 full-text articles. We found 16 articles (2 systematic reviews and 13 primary studies published in 14 publications) that met our eligibility criteria (Figure 1).^{19, 30–44} A listing of studies excluded during full-text review is included in Appendix B. Information abstracted from each included primary study is provided in Table 1.

Figure 1

Results of the search and screening.

3.2. Findings

Our literature search identified 19 systematic reviews. However, seven reviews are outdated (i.e., greater than 10 years from publication),^{2, 45–50} two are more narrowly focused than our scope,^{11, 51} eight are more broadly focused than our scope in terms of interventions or methods (such as integrative reviews),^{12, 52–58} and/or reached inconclusive results.

The two most relevant to our scope, Muller et al., 2018 and Lo et al., 2021, are discussed in the section about SBAR.^{19, 44}

3.2.1. Review Question: Based on the Evidence Published During the Included Dates, How Effective are Handoff Protocols, and What Are the Unintended Effects?

This review identified 13 studies published in 14 publications.^30–43 Four of the included studies were randomized trials^{32, 35, 41, 43} while the remainder were pre-post studies; two studies were performed in Argentina,^{31, 32} one each were performed in Taiwan,⁴² Canada,⁴¹ and Germany,⁴³ and the rest were performed in the United States. Six studies were performed at multiple sites, and the rest were single site studies. The most commonly studied handoff tool was I-PASS, in either its original or modified form (or precursor), which was the subject of 10 studies, with 2 studies of SBAR or its derivatives,^{42, 43} and 1 study of iHAND and SIGNOUT?.⁴¹ Most studies were conducted in academic teaching hospitals, and almost all studies assessed physician-to-physician handoffs. Most studies had numerous cointerventions/implementation strategies.

3.2.1.1. Risk of Bias

Four of the included studies were randomized trials.^{32, 35, 41, 43} No trial was judged to be at low risk of bias in all domains. However, the domain of blinding participants is very challenging to satisfy for this kind of intervention. Although studies are scored as high risk of bias for this domain, we did not place much weight on this assessment when considering the internal validity of the randomized trials. The remaining studies used a pre-post design. In assessing these studies, for the domain of delivering the intervention consistently across the study population, we considered any deviations to be a measure of real-world implementation and not a measure of internal validity. Thus all studies scored well on this domain. Although the pre-post studies all scored well using the modified NIH Tool (except for 2 studies with very small sample sizes), our assessment of their risk of bias remains high due to the inherent limitations of the study design. The risk of bias ratings for each study are listed in Appendix C.

3.2.1.2. Results for Specific Handoff Tools

3.2.1.2.1. SBAR (Situation, Background, Assessment, Recommendation) and Its Derivatives

We identified one good-quality systematic review about the impact of the use of SBAR for patient handoffs on patient safety.¹⁹ This review searched through January 2017 for studies focused on SBAR implementation into the clinical routine (and not a multidimensional QI intervention of which SBAR was just 1 component) with at least one clinical outcome reported. The systematic review identified 11 records: 8 pre-post studies and 1 RCT. Seven studies were conducted in hospitals. Nurses were the clinicians in all included studies, while in 5 studies additional other staff also were trained in SBAR use. Some studies used SBAR specifically in handoffs, and some studies used SBAR for communication in general. In 3 of the 7 studies performed in hospitals, SBAR was used only in a single unit. All studies assessed use of SBAR by nurses, but 5 studies included other clinicians such as physicians. The outcomes assessed were a heterogenous mixture of specific events like falls or patient mortality and composite outcomes such as “sentinel events” or “adverse patient events.” The synthesis of results was narrative. The authors stated that “five of the studies found significantly improved patient safety outcomes” and “four other studies reported descriptive improved patient outcomes,” and concluded that there is the potential for SBAR to “improve telephone communication from nurse to doctors in critical situations, general patient handoff, [and] team communication in general.” But the authors noted that the quality of evidence was low and no benefit was observed in one-third of studies.

We identified a related good quality systematic review about SBAR.⁴⁴ Although the review is not focused on clinical efficacy, we discuss it here for the purpose of continuity. The systematic review assessed the degree to which SBAR can be implemented with high fidelity. It searched through October 2020 for studies where SBAR was taught to structure verbal communication between healthcare providers or trainees, used a controlled trial design, and reported any of the outcomes of fidelity to SBAR, clarity of communication, clinical outcomes, or measures such as teamwork and patient safety climate. The authors identified 28 eligible studies. Most studies were conducted in hospital general or surgical wards or post-anesthesia care units, 15 were studies where SBAR was used for handoffs, and almost 75 percent involved nurses. Ten studies reported on a heterogenous mix of clinical outcomes such as mortality, unplanned ICU admissions, adverse events, readmissions, and urinary catheter removal. As the authors state, “Unfortunately, none of these studies also assessed communication clarity or fidelity.” The authors found that studies of SBAR implementation reporting large improvements in fidelity all occurred in classroom settings, and studies in clinical settings reported only small-to-moderate improvements. The authors concluded that “if organizations want to achieve the intended impact of SBAR, they need to attend to its implementation and ongoing monitoring.”

Two new research studies of SBAR or its variants were identified. One study was a pre-post study of nurse-to-physician communication in an obstetric ward in Taiwan,⁴² and thus of only limited relevance to this review’s focus on within-unit handoffs. The other study was an RCT in Germany that assessed the SBAR variant ISBAR₃ (Identification, Situation, Background, Assessment, Recommendation, Read-back, Risk)⁴³ in 7 ICU wards. The ISBAR₃ checklist was delivered as an iPad Mini application. Physicians received “brief instructions for using the tablets” and were instructed to use the checklists as an aid during shift-to-shift transfers, which took place twice a day. Control time periods involved use of the iPad but with a different checklist—VICUR (vaccination status, insurance status, contact person, utilization, rehabilitation)—to help minimize Hawthorne effects. During the time periods of the study, there were 1,038 admissions to the ICU that met the inclusion criteria, and they were cared for by 61 physicians (61% of these were residents). Compared to control, there was no statistically significant difference in the 3 clinical outcomes: mortality, length of stay, and reuptake (readmission) to the ICU. Patients cared for during the ISBAR₃ time period had better sepsis-related organ failure assessments during the first 24 hours. The authors concluded that “medical handovers are a burning issue. . . the present pilot study illustrates the complexity of the topic and shows both the potential and pitfalls concerning outcome parameters. . .”

3.2.1.2.2. I-PASS (Illness Severity, Patient Summary, Action List, Situation Awareness and Contingency Plans, and Synthesis to Receiver)

We identified 10 studies about 9 implementations of I-PASS or modifications.^{30–36, 38–40} We also include one study³⁷ here based on SIGNOUT? as it was the precursor study to I-PASS. The I-PASS Handoff Bundle as described in its landmark study³⁹ consisted of the mnemonic, which serves as the anchoring component for all else and a number of implementation techniques and strategies. These included a 2-hour workshop (part of which was devoted to Team Strategies, and Tools to Enhance Performance and Safety (TeamSTEPPS)), a 1-hour role-playing and simulation session, a computer module for use in independent learning, a faculty development program, direct-observation tools for use by faculty to provide feedback, and a culture-change campaign. In the precursor study,37 the mnemonic used was SIGNOUT? (SIGNOUT? is a mnemonic for Sick or DNR?, Identifying data, General hospital course, New events of day, Overall health status, Upcoming possibilities with plan, Tasks to complete overnight with plan, ? Any questions). The precursor bundle included relocation of the handoff to a private and quiet space and the restructuring of separate house staff handoffs into a unified team handoff, but did not include a faculty development program, tools, or the culture change campaign.

The precursor intervention was implemented in a pre-post study in two general pediatric wards in a pediatric residency program teaching hospital.³⁷ (Starmer 2013). The handoffs were shift-to-shift changes of physicians, both interns and residents. The outcomes were medical errors (defined as a failure in process of care) and adverse events (defined as preventable and nonpreventable unintended consequences of care that lead to patient harm). Error reports from clinicians and formal incident reports were solicited daily. Each suspected incident was reviewed by physician investigators blinded to intervention status. Among 1,255 patient admissions (almost evenly balanced between the pre- and post-intervention periods), the overall medical error rate reduced from 33.8 errors per 100 admissions to 18.3 errors per 100 admissions (p<0.001). Preventable adverse events decreased from 3.3 per 100 admissions to 1.5 per 100 admissions (p=0.04). Other measures of harmful and nonharmful errors also decreased. Written handoff documentation increased markedly overall, but one unit, which used a computerized handoff tool, substantially outperformed the other unit.

The same investigators (Starmer 2014) then revised their mnemonic to I-PASS, added the faculty components and culture change campaign, and conducted a pre-post study in 9 pediatric residency training programs.³⁹ Outcomes were medical errors and adverse events. Among 5,516 preintervention and 5,224 postintervention admissions medical errors reduced from 24.5 per 100 admissions preintervention to 18.8 per 100 admissions post intervention (p<0.001). Preventable adverse events decreased from 4.7 per 100 admissions to 3.3 per 100 admissions (p<0.001). Other measures of harm declined, but the rate of falls, medication errors, procedure-related errors, or nosocomial infections did not change. Three sites did not find statistically significant reductions in errors, and one site found more errors after implementation. Written handoff documentation greatly increased in almost all domains.

Eight additional I-PASS studies were subsequently conducted, adapting it for use in orthopedics,⁴⁰ in palliative care,³¹ in the intensive care unit,^{32, 35} to include a daily “rounds report” for families,^{33, 34} to be implemented as part of the EHR and/or in family medicine residency inpatient units,^{30, 36} and a broader study of implementation conducted by the original I-PASS investigator.³⁸ Not all of these studies reported statistically significant effects of the intervention on clinical safety outcomes. Some studies did not use the same outcome measures as the original I-PASS study, and other clinical safety outcomes (e.g., 30-day readmission, surgical site infection, reintubations within 24 hours) may not be as sensitive as the outcomes used in the original I-PASS studies. The benefits of I-PASS have not been as convincingly demonstrated in implementation studies outside the original development team.⁵⁹

3.2.1.2.3. Other Handoff Tools

We identified one study on the iHAND handoff tool,⁴¹ but since it was the only study of this tool and it was a single-site study, we do not discuss it in detail here, as it is not possible to consider tool intervention effects separate from context effects. Data about the study are in the Evidence Table (Table 2). We did not find any studies of any of the other structured tools.

3.2.1.2.4. Certainty of Evidence

We judged the certainty of evidence that the use of I-PASS reduces medical errors and adverse events as moderate, uprated from low (based on study design) due to use of theory/logic models, the beneficial effect of similar interventions in other areas of public safety (such as air travel), assessments of context, and reporting of implementation process (see Appendix Table C-3). We agreed with the systematic review on SBAR that the certainty/quality of evidence for the effect of SBAR on those same outcomes is low. No other tool had sufficient evidence to assess.

Table 2

Evidence table of primary studies included.

3.2.1.3. Common Barriers and Facilitators to Implementation of Handoff Protocols

Most of the included studies did not specifically comment on barriers and facilitators. Two studies cited resistance to change as a barrier,³² and education and monitoring, prompt responses to questions, and use of a resident champion in leadership as facilitators.⁴⁰ The amount of time needed for the handoff (using as compared to not using the handoff tool) may also be a potential barrier, as several studies also measured this as an outcome (studies showed negligible or even no differences in time).

3.2.1.4. Resources (Such as Cost, Staff, Time) Required for Implementation of Handoff Protocols

No studies reported specific information about resources required for implementation. However, several studies report in great detail the other co-intervention or implementation strategies used when implementing the handoff protocol,^{32–34, 37–39} and these are recorded in the evidence table. These are best described for the I-PASS tool, such that they are considered part of the intervention and include multiple and repeated trainings, role play, medical faculty education, direct observation, culture-change campaign, and use of clinical champions.

3.2.1.5. Toolkits To Support Implementation of Handoff Protocols

We found several published studies on I-PASS toolkits.^{30–33, 35–40} In addition, there is the I-PASS Institute (www.ipassinstitute.com) that contains links to tools.

Table 3 lists our internet search results on the other 11 patient handoff communication tools specified in the inclusion criteria.

Table 3

Toolkits results.

4. Discussion

5. References

1.

Agency for Healthcare Research and Quality. Tool: Handoff. Rockville, MD; May 2023. https://www​.ahrq.gov​/teamstepps-program/curriculum​/communication/tools/handoff​.html. Accessed on June 4, 2024.

2.

Robertson ER, Morgan L, Bird S, et al Interventions employed to improve intrahospital handover: a systematic review. BMJ Qual Saf. 2014 Jul;23(7):600–7. doi: 10.1136/bmjqs-2013-002309. PMID: 24811239. [PubMed: 24811239] [CrossRef]

3.

The Joint Commission. Inadequate hand-off communication. Sentinel event alert. 2017 09/2017;58(58):1–6. [PubMed: 28914519]

4.

Shekelle P, Wachter RM, Pronovost PJ, et al Making Healthcare Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Evidence report/technology assessment. 2013;211:1–945. [PMC free article: PMC4781147] [PubMed: 24423049]

5.

Hall KK, Shoemaker-Hunt S, Hoffman L, et al Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. Rockville (MD); 2020. [PubMed: 32255576]

6.

Abraham J, Duffy C, Kandasamy M, et al An evidence synthesis on perioperative Handoffs: A call for balanced sociotechnical solutions. Int J Med Inform. 2023 Jun;174:105038. doi: 10.1016/j.ijmedinf.2023.105038. PMID: 36948060. [PubMed: 36948060] [CrossRef]

7.

Abraham J, Pfeifer E, Doering M, et al Systematic review of intraoperative anesthesia handoffs and handoff tools. Anesth Analg. 2021 Jun 1;132(6):1563–75. doi: 10.1213/ane.0000000000005367. PMID: 34032660. [PubMed: 34032660] [CrossRef]

8.

Boet S, Djokhdem H, Leir SA, et al Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis. Br J Anaesth. 2020 Oct;125(4):605–13. doi: 10.1016/j.bja.2020.05.062. PMID: 32682560. [PMC free article: PMC9520752] [PubMed: 32682560] [CrossRef]

9.

Lazzara EH, Simonson RJ, Gisick LM, et al Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes. Ergonomics. 2022 Aug;65(8):1138–53. doi: 10.1080/00140139.2021.2020341. PMID: 35438045. [PubMed: 35438045] [CrossRef]

10.

Møller TP, Madsen MD, Fuhrmann L, et al Postoperative handover: characteristics and considerations on improvement: a systematic review. Eur J Anaesthesiol. 2013 May;30(5):229–42. doi: 10.1097/EJA.0b013e32835d8520. PMID: 23492933. [PubMed: 23492933] [CrossRef]

11.

Pucher PH, Johnston MJ, Aggarwal R, et al Effectiveness of interventions to improve patient handover in surgery: A systematic review. Surgery. 2015 Jul;158(1):85–95. doi: 10.1016/j.surg.2015.02.017. PMID: 25999255. [PubMed: 25999255] [CrossRef]

12.

Rosenthal JL, Doiron R, Haynes SC, et al The effectiveness of standardized handoff tool interventions during inter- and intra-facility care transitions on patient-related outcomes: a systematic review. Am J Med Qual. 2018 Mar/Apr;33(2):193–206. doi: 10.1177/1062860617708244. PMID: 28467104. [PubMed: 28467104] [CrossRef]

13.

Wibrandt I, Lippert A. Improving patient safety in handover from intensive care unit to general ward: a systematic review. J Patient Saf. 2020 Sep;16(3):199–210. doi: 10.1097/pts.0000000000000266. PMID: 28452913. [PubMed: 28452913] [CrossRef]

14.

Hilligoss B, Cohen MD. The unappreciated challenges of between-unit handoffs: negotiating and coordinating across boundaries. Ann Emerg Med. 2013 Feb;61(2):155–60. doi: 10.1016/j.annemergmed.2012.04.009. PMID: 22560466. [PubMed: 22560466] [CrossRef]

15.

Desai SV, Feldman L, Brown L, et al Effect of the 2011 vs 2003 duty hour regulation-compliant models on sleep duration, trainee education, and continuity of patient care among internal medicine house staff: A randomized trial. JAMA Internal Medicine. 2013;173(8):649–55. doi: 10.1001/jamainternmed.2013.2973. [PubMed: 23529771] [CrossRef]

16.

Appelbaum R, Martin S, Tinkoff G, et al Eastern association for the surgery of trauma - quality, patient safety, and outcomes committee -transitions of care: healthcare handoffs in trauma. Am J Surg. 2021 Sep;222(3):521–8. doi: 10.1016/j.amjsurg.2021.01.034. PMID: 33558061. [PubMed: 33558061] [CrossRef]

17.

Keebler JR, Lazzara EH, Patzer BS, et al Meta-Analyses of the effects of standardized handoff protocols on patient, provider, and organization outcomes. Hum Factors. 2016 Dec;58(8):1187–205. doi: 10.1177/0018720816672309. PMID: 27821676. [PubMed: 27821676] [CrossRef]

18.

Jewell JA. Standardization of inpatient handoff communication. Pediatrics. 2016 Nov;138(5). doi: 10.1542/peds.2016-2681. PMID: 27940799. [PubMed: 27940799] [CrossRef]

19.

Müller M, Jürgens J, Redaèlli M, et al Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review. BMJ Open. 2018 Aug 23;8(8):e022202. doi: 10.1136/bmjopen-2018-022202. PMID: 30139905. [PMC free article: PMC6112409] [PubMed: 30139905] [CrossRef]

20.

Ransom B, Winters K. The I-PASS mnemonic and the occurrence of handoff related errors in adult acute care hospitals: a systematic review protocol. JBI Database System Rev Implement Rep. 2018 Jan;16(1):21–6. doi: 10.11124/jbisrir-2016-003303. PMID: 29324551. [PubMed: 29324551] [CrossRef]

21.

EPC Program Procedures Guide. Rockville, MD: Agency for Healthcare Research and Quality; 2021. https:​//effectivehealthcare​.ahrq.gov/about/epc.; 2021.

22.

U.S. Preventive Services Task Force. U.S. Preventive Services Task Force Procedure Manual. Appendix VI. Criteria for Assessing Internal Validity of Individual Studies. U.S. Preventive Services Task Force. July 2017. https://www​.uspreventiveservicestaskforce​.org/uspstf/about-uspstf​/methods-and-processes​/procedure-manual​/procedure-manual-appendix-vi-criteria-assessing-internal-validity-individual-studies. 2017.

23.

Higgins JP, Altman DG, Gotzsche PC, et al The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ. 2011 Oct 18;343:d5928. doi: 10.1136/bmj.d5928. PMID: 22008217. [PMC free article: PMC3196245] [PubMed: 22008217] [CrossRef]

24.

Sterne JA, Hernan MA, Reeves BC, et al ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016 Oct 12;355:i4919. doi: 10.1136/bmj.i4919. PMID: 27733354. [PMC free article: PMC5062054] [PubMed: 27733354] [CrossRef]

25.

National Heart, Lung, and Blood Institute. Study Quality Assessment Tools. https://www​.nhlbi.nih​.gov/health-topics/study-quality-assessment-tools. Accessed September 6, 2024.

26.

Methods Guide for Effectiveness and Comparative Effectiveness Reviews. AHRQ Publication No. 10(14)-EHC063-EF. Agency for Healthcare Research and Quality. Rockville, MD: 2014. https:​//effectivehealthcare​.ahrq.gov/sites​/default/files/pdf​/cer-methods-guide_overview.pdf. [PubMed: 21433403]

27.

Shekelle PG, Wachter RM, Pronovost PJ, et al Making health care safer II: an updated critical analysis of the evidence for patient safety practices. Evid Rep Technol Assess (Full Rep). 2013 Mar(211):1–945. PMID: 24423049. [PMC free article: PMC4781147] [PubMed: 24423049]

28.

Calonge N, Shekelle PG, Owens DK, et al A framework for synthesizing intervention evidence from multiple sources into a single certainty of evidence rating: Methodological developments from a US National Academies of Sciences, Engineering, and Medicine Committee. Research Synthesis Methods. 2023;14(1):36–51. doi: 10.1002/jrsm.1582. [PMC free article: PMC10084284] [PubMed: 35722864] [CrossRef]

29.

Downey A, Brown L, Calonge N, et al National Academies of Sciences, Engineering, Medicine. In: Evidence-Based Practice for Public Health Emergency Preparedness and Response. Washington: 2020. [PubMed: 32662819]

30.

Dewar ZE, Yurkonis T, Attia M. Hand-off bundle implementation associated with decreased medical errors and preventable adverse events on an academic family medicine in-patient unit: A pre-post study. Medicine (Baltimore). 2019 Oct;98(40):e17459. doi: 10.1097/md.0000000000017459. PMID: 31577774. [PMC free article: PMC6783144] [PubMed: 31577774] [CrossRef]

31.

Goldraij G, Tripodoro VA, Aloisio M, et al One chance to get it right: improving clinical handovers for better symptom control at the end of life. BMJ Open Qual. 2021 Sep;10(3). doi: 10.1136/bmjoq-2021-001436. PMID: 34588188. [PMC free article: PMC8483039] [PubMed: 34588188] [CrossRef]

32.

Jorro-Baróon F, Suarez-Anzorena I, Burgos-Pratx R, et al Handoff improvement and adverse event reduction programme implementation in paediatric intensive care units in Argentina: a stepped-wedge trial. BMJ Qual Saf. 2021 Oct;30(10):782–91. doi: 10.1136/bmjqs-2020-012370. PMID: 33893213. [PubMed: 33893213] [CrossRef]

33.

Khan A, Spector ND, Baird JD, et al Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. BMJ. 2018 Dec 5;363:k4764. doi: 10.1136/bmj.k4764. PMID: 30518517. [PMC free article: PMC6278585] [PubMed: 30518517] [CrossRef]

34.

Kuzma N, Khan A, Rickey L, et al Effect of patient and family centered I-PASS on adverse event rates in hospitalized children with complex chronic conditions. J Hosp Med. 2023 Apr;18(4):316–20. doi: 10.1002/jhm.13065. PMID: 36788740. [PubMed: 36788740] [CrossRef]

35.

Parent B, LaGrone LN, Albirair MT, et al Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care unit: a stepped-wedge cluster randomized clinical trial. JAMA Surg. 2018 May l;153(5):464–70. doi: 10.1001/jamasurg.2017.5440. PMID: 29299602. [PMC free article: PMC5875375] [PubMed: 29299602] [CrossRef]

36.

Sonoda K, Nakaishi L, Salter C. Standardizing sign-out with I-PASS handoff in family medicine residency. PRiMER. 2021;5:8. doi: 10.22454/PRiMER.2021.678175. PMID: 33860163. [PMC free article: PMC8041220] [PubMed: 33860163] [CrossRef]

37.

Starmer AJ, Sectish TC, Simon DW, et al Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013 Dec 4;310(21):2262–70. doi: 10.1001/jama.2013.281961. PMID: 24302089. [PubMed: 24302089] [CrossRef]

38.

Starmer AJ, Spector ND, O'Toole JK, et al Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. J Hosp Med. 2023 Jan;18(l):5–14. doi: 10.1002/jhm.12979. PMID: 36326255. [PMC free article: PMC10964397] [PubMed: 36326255] [CrossRef]

39.

Starmer AJ, Spector ND, Srivastava R, et al Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014 Nov 6;371(19): 1803–12. doi: 10.1056/NEJMsa1405556. PMID: 25372088. [PubMed: 25372088] [CrossRef]

40.

Stenquist DS, Yeung CM, Szapary HJ, et al Sustained improvement in quality of patient handoffs after orthopaedic surgery I-PASS intervention. J Am Acad Orthop Surg Glob Res Rev. 2022 Sep 1;6(9). doi: 10.5435/JAAOSGlobal-D-22-00079. PMID: 36067218. [PMC free article: PMC9447790] [PubMed: 36067218] [CrossRef]

41.

Tam P, Nijjar AP, Fok M, et al Structured patient handoff on an internal medicine ward: a cluster randomized control trial. PLoS One. 2018;13(4):e0195216. doi: 10.1371/journal.pone.0195216. PMID: 29672526. [PMC free article: PMC5908079] [PubMed: 29672526] [CrossRef]

42.

Ting WH, Peng FS, Lin HH, et al The impact of situation-background-assessment-recommendation (SBAR) on safety attitudes in the obstetrics department. Taiwan J Obstet Gynecol. 2017 Apr;56(2):171–4. doi: 10.1016/j.tjog.2016.06.021. PMID: 28420502. [PubMed: 28420502] [CrossRef]

43.

Verholen N, Vogt L, Klasen M, et al Do digital handover checklists influence the clinical outcome parameters of intensive care unit patients? A randomized controlled pilot study. Front Med (Lausanne). 2021;8:661343. doi: 10.3389/fmed.2021.661343. PMID: 33959627. [PMC free article: PMC8093756] [PubMed: 33959627] [CrossRef]

44.

Lo L, Rotteau L, Shojania K. Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review. BMJ Open. 2021 Dec 17;11(12):e055247. doi: 10.1136/bmjopen-2021-055247. PMID: 34921087. [PMC free article: PMC8685965] [PubMed: 34921087] [CrossRef]

45.

Anderson J, Malone L, Shanahan K, et al Nursing bedside clinical handover - an integrated review of issues and tools. J Clin Nurs. 2015 Mar;24(5–6):662–71. doi: 10.1111/jocn.12706. PMID: 25319724. [PubMed: 25319724] [CrossRef]

46.

Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care. 2010 Dec;19(6):493–7. doi: 10.1136/qshc.2009.033480. PMID: 20378628. [PubMed: 20378628] [CrossRef]

47.

Li P, Ali S, Tang C, et al Review of computerized physician handoff tools for improving the quality of patient care. Journal of Hospital Medicine. 2013;8(8):456–63. doi: 10.1002/jhm.1988. [PubMed: 23169534] [CrossRef]

48.

Riesenberg LA, Leitzsch J, Cunningham JM. Nursing handoffs: a systematic review of the literature. Am J Nurs. 2010 Apr;110(4):24–34; quiz 5–6. doi: 10.1097/01.NAJ.0000370154.79857.09. PMID: 20335686. [PubMed: 20335686] [CrossRef]

49.

Riesenberg LA, Leitzsch J, Little BW. Systematic review of handoff mnemonics literature. Am J Med Qual. 2019 Sep/Oct;34(5):446–54. doi: 10.1177/1062860619873200. PMID: 31479296. [PubMed: 31479296] [CrossRef]

50.

Holly C, Poletick EB. A systematic review on the transfer of information during nurse transitions in care. J Clin Nurs. 2013 Sep;23(17–18):2387–95. doi: 10.1111/jocn.12365. PMID: 23786673. [PubMed: 23786673] [CrossRef]

51.

Bukoh MX, Siah CR. A systematic review on the structured handover interventions between nurses in improving patient safety outcomes. J Nurs Manag. 2020 Apr;28(3):744–55. doi: 10.1111/jonm.12936. PMID: 31859377. [PubMed: 31859377] [CrossRef]

52.

Appelbaum RD, Puzio TJ, Bauman Z, et al Handoffs and transitions of care: a systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2024 Feb 26. doi: 10.1097/ta.0000000000004285. PMID: 38407300. [PubMed: 38407300] [CrossRef]

53.

Bakon S, Wirihana L, Christensen M, et al Nursing handovers: an integrative review of the different models and processes available. Int J Nurs Pract. 2017 Apr;23(2). doi: 10.1111/ijn.12520. PMID: 28176414. [PubMed: 28176414] [CrossRef]

54.

Boyd J, Wu G, Stelfox H. The impact of checklists on inpatient safety outcomes: a systematic review of randomized controlled trials. J Hosp Med. 2017 Aug;12(8):675–82. doi: 10.12788/jhm.2788. PMID: 28786436. [PubMed: 28786436] [CrossRef]

55.

Cho S, Lee JL, Kim KS, et al Systematic review of quality improvement projects related to intershift nursing handover. J Nurs Care Qual. 2022 Jan-Mar 01;37(1):E8–e14. doi: 10.1097/ncq.0000000000000576. PMID: 34231504. [PubMed: 34231504] [CrossRef]

56.

Hada A, Coyer F. Shift-to-shift nursing handover interventions associated with improved inpatient outcomes-falls, pressure injuries and medication administration errors: an integrative review. Nurs Health Sci. 2021 Jun;23(2):337–51. doi: 10.1111/nhs.12825. PMID: 33665950. [PubMed: 33665950] [CrossRef]

57.

Mardis M, Davis J, Benningfield B, et al Shift-to-shift handoff effects on patient safety and outcomes. Am J Med Qual. 2017 Jan/Feb;32(1):34–42. doi: 10.1177/1062860615612923. PMID: 26518882. [PubMed: 26518882] [CrossRef]

58.

Odone A, Bossi E, Scardoni A, et al Physician-to-nurse handover: a systematic review on the effectiveness of different models. J Patient Saf. 2022 Jan 1;18(1):e73–e84. doi: 10.1097/pts.0000000000000701. PMID: 32433435. [PubMed: 32433435] [CrossRef]

59.

Shahian D. I-PASS handover system: a decade of evidence demands action. BMJ Qual Saf. 2021 Oct;30(10):769–74. doi: 10.1136/bmjqs-2021-013314. PMID: 33893212. [PubMed: 33893212] [CrossRef]

Acknowledgments

The authors would like to thank Ellen S. Deutsch, M.D., M.S., FACS, FAAP, FSSH, and Karen Cosby, M.D., FACEP, CPPS, for their review and input on the report.

Peer Reviewers

The list of peer reviewers follows:

• Vineet Arora, M.D., M.A.P.P.
  Herbert T. Abelson Professor of Medicine
  Dean for Medical Education, The Pritzker School of Medicine
  University of Chicago
  Chicago, IL
• Lekshmi Santhosh, M.D., M.A.Ed.
  Department of Medicine Associate Chair for People Development and Mentorship
  Associate Professor of Clinical Medicine, Pulmonary and Critical Care and Hospital Medicine
  Associate Program Director, Pulmonary and Critical Care Fellowship
  Associate Program Director, Internal Medicine Residency
  Director, Department of Medicine Medical Grand Rounds
  Gold-Headed Cane Endowed Education Chair in Internal Medicine
  University of California, San Francisco
  San Francisco, CA
• Sallie Weaver, Ph.D., M.H.S.
  Senior Scientist and Program Director
  Health Systems and Interventions Research Branch
  National Cancer Institute
  Bethesda, MD

Afterword

Recognized for excellence in conducting comprehensive systematic reviews, the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program is developing a range of rapid evidence products to assist end users in making specific decisions in a limited timeframe. AHRQ recognizes that people are struggling with urgent questions on how to make healthcare safer. AHRQ is using this rapid format for the fourth edition of its Making Healthcare Safer series of reports, produced by the EPC Program and the General Patient Safety Program. To shorten timelines, reviewers make strategic choices about which processes to abridge. However, the adaptations made for expediency may limit the certainty and generalizability of the findings from the review, particularly in areas with a large literature base. Transparent reporting of the methods used and the resulting limitations of the evidence synthesis are extremely important.

AHRQ expects that these rapid evidence products will be helpful to health plans, providers, purchasers, government programs, and the healthcare system as a whole. Transparency and stakeholder input are essential to AHRQ. If you have comments related to this report, they may be sent by mail to the Task Order Officer named below at: Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, MD 20857, or by email to vog.shh.qrha@SHM.

• Robert Otto Valdez, Ph.D., M.H.S.A.
  Director
  Agency for Healthcare Research and Quality
• Therese Miller, D.P.H.
  Director
  Center for Evidence and Practice Improvement
  Agency for Healthcare Research and Quality
• Christine Chang, M.D., M.P.H.
  Director
  Evidence-based Practice Center Division
  Center for Evidence and Practice Improvement
  Agency for Healthcare Research and Quality
• David W. Niebuhr, M.D., M.P.H., M.Sc.
  Evidence-based Practice Center Division Liaison
  Center for Evidence and Practice Improvement
  Agency for Healthcare Research and Quality
• Craig A. Umscheid, M.D., M.S.
  Director
  Center for Quality Improvement and Patient Safety
  Agency for Healthcare Research and Quality
• Margie Shofer, B.S.N., M.B.A.
  Director, General Patient Safety Program
  Center for Quality Improvement and Patient Safety
  Agency for Healthcare Research and Quality
• Farzana Samad, Pharm.D., FISMP, CPPS
  Health Scientist Administrator
  Center for Quality Improvement and Patient Safety
  Agency for Healthcare Research and Quality

Appendix A. Methods

Appendix B. List of Studies Excluded Upon Full-Text Review

1.

Study: new approach to handoffs slashes errors, preventable adverse events; other medical centers move to implement the protocol. ED Manag. 2015 Jan;27(1):6–8. PMID: 25564696. Design [PubMed: 25564696]

2.

Abraham J, Duffy C, Kandasamy M, et al An evidence synthesis on perioperative Handoffs: A call for balanced sociotechnical solutions. Int J Med Inform. 2023 Jun;174:105038. doi: 10.1016/j.ijmedinf.2023.105038. PMID: 36948060. Background [PubMed: 36948060] [CrossRef]

3.

Abraham J, Pfeifer E, Doering M, et al Systematic review of intraoperative anesthesia handoff tools. Anesth Analg. 2021 Jun 1;132(6):1563–75. doi: 10.1213/ane.0000000000005367. PMID: 34032660. Anesthesia handoffs [PubMed: 34032660] [CrossRef]

4.

Agency for Healthcare Research and Quality. TeamSTEPPS Updates. Rockville, MD; February 2024. https://www​.ahrq.gov​/teamsteppsprogram/updated/index.html. Accessed on June 4, 2024. Does not measure clinical safety outcome

5.

Agency for Healthcare Research and Quality. Tool: Handoff. Rockville, MD; May 2023. https://www​.ahrq.gov​/teamsteppsprogram/curriculum​/communication/tools/handoff​.html. Accessed on June 4, 2024. Does not measure clinical safety outcome

6.

Alimenti D, Buydos S, Cunliffe L, et al Improving perceptions of patient safety through standardizing handoffs from the emergency department to the inpatient setting: a systematic review. J Am Assoc Nurse Pract. 2019 Jun 5;31(6):354–63. doi: 10.1097/jxx.0000000000000160. PMID: 30829973. Between unit handoffs [PubMed: 30829973] [CrossRef]

7.

Anderson J, Malone L, Shanahan K, et al Nursing bedside clinical handover - an integrated review of issues and tools. J Clin Nurs. 2015 Mar;24(5–6):662–71. doi: 10.1111/jocn.12706. PMID: 25319724. SR outdated [PubMed: 25319724] [CrossRef]

8.

Appelbaum R, Martin S, Tinkoff G, et al Eastern association for the surgery of trauma -quality, patient safety, and outcomes committee - transitions of care: healthcare handoffs in trauma. Am J Surg. 2021 Sep;222(3):521–8. doi: 10.1016/j.amjsurg.2021.01.034. PMID: 33558061. Between unit handoffs [PubMed: 33558061] [CrossRef]

9.

Appelbaum RD, Puzio TJ, Bauman Z, et al Handoffs and transitions of care: a systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2024 Feb 26. doi: 10.1097/ta.0000000000004285. PMID: 38407300. SR broadly focused [PubMed: 38407300] [CrossRef]

10.

Bakon S, Wirihana L, Christensen M, et al Nursing handovers: an integrative review of the different models and processes available. Int J Nurs Pract. 2017 Apr;23(2). doi: 10.1111/ijn.12520. PMID: 28176414. SR broadly focused [PubMed: 28176414] [CrossRef]

11.

Becker's Clinical Leadership. 12 patient handoff communication tools to know. Clinical Leadership & Infection Control. June 29, 2016. Does not measure clinical safety outcome

12.

Benjamin MF, Hargrave S, Nether K. Using the Targeted Solutions Tool® to improve emergency department handoffs in a community hospital. Jt Comm J Qual Patient Saf. 2016 Mar;42(3):107–18. doi: 10.1016/s1553-7250(16)42013-1. PMID: 26892699. Outpatient [PubMed: 26892699] [CrossRef]

13.

Blazin LJ, Sitthi-Amorn J, Hoffman JM, et al Improving patient handoffs and transitions through adaptation and implementation of I-PASS across multiple handoff settings. Pediatr Qual Saf. 2020 Jul-Aug;5(4):e323. doi: 10.1097/pq9.0000000000000323. PMID: 32766496. Does not measure clinical safety outcomes [PMC free article: PMC7382547] [PubMed: 32766496] [CrossRef]

14.

Boet S, Djokhdem H, Leir SA, et al Association of intraoperative anaesthesia handovers with patient morbidity and mortality: a systematic review and meta-analysis. Br J Anaesth. 2020 Oct;125(4):605–13. doi: 10.1016/j.bja.2020.05.062. PMID: 32682560. Anesthesia handoffs [PMC free article: PMC9520752] [PubMed: 32682560] [CrossRef]

15.

Bowes MR, Santiago PN, Hepps JH, et al Using I-PASS in psychiatry residency transitions of care. Acad Psychiatry. 2018 Aug;42(4):534–7. doi: 10.1007/s40596-017-0822-1. PMID: 29086242. Design [PubMed: 29086242] [CrossRef]

16.

Boyd J, Wu G, Stelfox H. The Impact of checklists on inpatient safety outcomes: a systematic review of randomized controlled trials. J Hosp Med. 2017 Aug;12(8):675–82. doi: 10.12788/jhm.2788. PMID: 28786436. SR broadly focused [PubMed: 28786436] [CrossRef]

17.

Bressan V, Mio M, Palese A. Nursing handovers and patient safety: findings from an umbrella review. J Adv Nurs. 2020 Apr;76(4):927–38. doi: 10.1111/jan.14288. PMID: 31815307. Background [PubMed: 31815307] [CrossRef]

18.

Bukoh MX, Siah CR. A systematic review on the structured handover interventions between nurses in improving patient safety outcomes. J Nurs Manag. 2020 Apr;28(3):744–55. doi: 10.1111/jonm.12936. PMID: 31859377. SR narrowly focused [PubMed: 31859377] [CrossRef]

19.

Caruso TJ, Su F, Wang E. Introduction of the EMR-integrated I-PASS ICU handoff tool. Pediatr Qual Saf. 2020 Jul-Aug;5(4):e334. doi: 10.1097/pq9.0000000000000334. PMID: 32766505. Design [PMC free article: PMC7382550] [PubMed: 32766505] [CrossRef]

20.

Chladek MS, Doughty C, Patel B, et al The standardisation of handoffs in a large academic paediatric emergency department using I-PASS. BMJ Open Qual. 2021 Jul;10(3). doi: 10.1136/bmjoq-2020-001254. PMID: 34244172. Does not measure clinical safety outcomes [PMC free article: PMC8273485] [PubMed: 34244172] [CrossRef]

21.

Cho S, Lee JL, Kim KS, et al Systematic review of quality improvement projects related to intershift nursing handover. J Nurs Care Qual. 2022 Jan-Mar 01;37(1):E8–e14. doi: 10.1097/ncq.0000000000000576. PMID: 34231504. SR broadly focused [PubMed: 34231504] [CrossRef]

22.

Clements K. High-reliability and the I-PASS communication tool. Nurs Manage. 2017 Mar;48(3):12–3. doi: 10.1097/01.NUMA.0000512897.68425.e5. PMID: 28234760. Design [PubMed: 28234760] [CrossRef]

23.

Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care. 2010 Dec;19(6):493–7. doi: 10.1136/qshc.2009.033480. PMID: 20378628. SR outdated [PubMed: 20378628] [CrossRef]

24.

Devlin MK, Kozij NK, Kiss A, et al Morning handover of on-call issues: opportunities for improvement. JAMA Intern Med. 2014 Sep;174(9):1479–85. doi: 10.1001/jamainternmed.2014.3033. PMID: 25047049. No intervention of interest [PubMed: 25047049] [CrossRef]

25.

Dewar ZE, Yurkonis T, Attia M. Hand-off bundle implementation associated with decreased medical errors and preventable adverse events on an academic family medicine inpatient unit: A pre-post study. Medicine (Baltimore). 2019 Oct;98(40):e17459. doi: 10.1097/md.0000000000017459. PMID: 31577774. Duplicate [PMC free article: PMC6783144] [PubMed: 31577774] [CrossRef]

26.

Farhan M, Brown R, Vincent C, et al The ABC of handover: impact on shift handover in the emergency department. Emerg Med J. 2012 Dec;29(12):947–53. doi: 10.1136/emermed-2011-200201. PMID: 22205783. Does not measure clinical safety outcomes [PubMed: 22205783] [CrossRef]

27.

Farhan M, Brown R, Woloshynowych M, et al The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department. Emerg Med J. 2012 Dec;29(12):941–6. doi: 10.1136/emermed-2011-200199. PMID: 22215174. Design [PMC free article: PMC3512350] [PubMed: 22215174] [CrossRef]

28.

Feraco AM, Starmer AJ, Sectish TC, et al Reliability of verbal handoff assessment and handoff quality before and after implementation of a resident handoff bundle. Acad Pediatr. 2016 Aug;16(6):524–31. doi: 10.1016/j.acap.2016.04.002. PMID: 27090858. Does not measure clinical safety outcomes [PMC free article: PMC5504880] [PubMed: 27090858] [CrossRef]

29.

Feraco AM, Starmer AJ, Sectish TC, et al Reliability of verbal handoff assessment and handoff quality before and after implementation of a resident handoff bundle. Acad Pediatr. 2016 Aug;16(6):524–31. doi: 10.1016/j.acap.2016.04.002. PMID: 27090858. Duplicate [PMC free article: PMC5504880] [PubMed: 27090858] [CrossRef]

30.

Fitzgerald KM, Banerjee TR, Starmer AJ, et al Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. Pediatr Qual Saf. 2022 Mar-Apr;7(2):e539. doi: 10.1097/pq9.0000000000000539. PMID: 35369417. Does not measure clinical safety outcome [PMC free article: PMC8970093] [PubMed: 35369417] [CrossRef]

31.

Franco Vega MC, Ait Aiss M, George M, et al Enhancing implementation of the I-PASS handoff tool using a provider handoff task force at a comprehensive cancer center. Jt Comm J Qual Patient Saf. 2024 Mar 8. doi: 10.1016/j.jcjq.2024.03.004. PMID: 38584053. Does not measure clinical safety outcome [PubMed: 38584053] [CrossRef]

32.

Fryman C, Hamo C, Raghavan S, et al A quality improvement approach to standardization and sustainability of the hand-off process. BMJ Qual Improv Rep. 2017;6(1). doi: 10.1136/bmjquality.u222156.w8291. PMID: 28469889. Does not measure clinical safety outcome [PMC free article: PMC5387931] [PubMed: 28469889] [CrossRef]

33.

Hada A, Coyer F. Shift-to-shift nursing handover interventions associated with improved inpatient outcomes-falls, pressure injuries and medication administration errors: an integrative review. Nurs Health Sci. 2021 Jun;23(2):337–51. doi: 10.1111/nhs.12825. PMID: 33665950. SR broadly focused [PubMed: 33665950] [CrossRef]

34.

Holly C, Poletick EB. A systematic review on the transfer of information during nurse transitions in care. J Clin Nurs. 2013 Sep;23(17–18):2387–95. doi: 10.1111/jocn.12365. PMID: 23786673. SR outdated [PubMed: 23786673] [CrossRef]

35.

Huth K, Hart F, Moreau K, et al Real-world implementation of a standardized handover program (I-PASS) on a pediatric clinical teaching unit. Acad Pediatr. 2016 Aug;16(6):532–9. doi: 10.1016/j.acap.2016.05.143. PMID: 27188521. Does not measure clinical safety outcomes [PubMed: 27188521] [CrossRef]

36.

Iedema R, Ball C, Daly B, et al Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO'. BMJ Qual Saf. 2012 Aug;21(8):627–33. doi: 10.1136/bmjqs-2011-000766. PMID: 22626739. Between unit handoffs [PubMed: 22626739] [CrossRef]

37.

Jewell JA. Standardization of inpatient handoff communication. Pediatrics. 2016 Nov;138(5). doi: 10.1542/peds.2016-2681. PMID: 27940799. Design [PubMed: 27940799] [CrossRef]

38.

Jiang SY, Murphy A, Heitkemper EM, et al Impact of an electronic handoff documentation tool on team shared mental models in pediatric critical care. J Biomed Inform. 2017 May;69:24–32. doi: 10.1016/j.jbi.2017.03.004. PMID: 28286030. Does not measure clinical safety outcomes [PMC free article: PMC5471109] [PubMed: 28286030] [CrossRef]

39.

Keebler JR, Lazzara EH, Patzer BS, et al Meta-analyses of the effects of standardized handoff protocols on patient, provider, and organizational outcomes. Hum Factors. 2016 Dec;58(8):1187–205. doi: 10.1177/0018720816672309. PMID: 27821676. Design [PubMed: 27821676] [CrossRef]

40.

Lam KC, Mok TS. Comparison is beyond IPASS and OPTIMAL. Hong Kong Med J. 2014 Jun;20(3):176–7. doi: 10.12809/hkmj144267. PMID: 24914076. No intervention of interest [PubMed: 24914076] [CrossRef]

41.

Lazzara EH, Simonson RJ, Gisick LM, et al Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes. Ergonomics. 2022 Aug;65(8):1138–53. doi: 10.1080/00140139.2021.2020341. PMID: 35438045. Anesthesia handoffs [PubMed: 35438045] [CrossRef]

42.

Li P, Ali S, Tang C, et al Review of computerized physician handoff tools for improving the quality of patient care. Journal of Hospital Medicine. 2013;8(8):456–63. doi: 10.1002/jhm.1988. SR outdated [PubMed: 23169534] [CrossRef]

43.

Mardis M, Davis J, Benningfield B, et al Shift-to-shift handoff effects on patient safety and outcomes. Am J Med Qual. 2017 Jan/Feb;32(1):34–42. doi: 10.1177/1062860615612923. PMID: 26518882. SR inconclusive results [PubMed: 26518882] [CrossRef]

44.

Mariano MT, Brooks V, DiGiacomo M. PSYCH: a mnemonic to help psychiatric residents decrease patient handoff communication errors. Jt Comm J Qual Patient Saf. 2016 Jul;42(7):316–20. doi: 10.1016/s1553-7250(16)42043-x. PMID: 27301835. Does not measure clinical safety outcomes [PubMed: 27301835] [CrossRef]

45.

Mathias JM. Targeted solutions tool helps banish communication barriers during surgery. OR Manager. 2014 Jan;30(1):14–6. PMID: 24520680. Design [PubMed: 24520680]

46.

Merten H, van Galen LS, Wagner C. Safe handover. BMJ. 2017 Oct 9;359:j4328. doi: 10.1136/bmj.j4328. PMID: 28993308. Design [PubMed: 28993308] [CrossRef]

47.

Methangkool E, Tollinche L, Sparling J, et al Communication: is there a standard handover technique to transfer patient care? Int Anesthesiol Clin. 2019 Summer;57(3):35–47. doi: 10.1097/aia.0000000000000241. PMID: 31577236. Design [PMC free article: PMC6777853] [PubMed: 31577236] [CrossRef]

48.

Møller TP, Madsen MD, Fuhrmann L, et al Postoperative handover: characteristics and considerations on improvement: a systematic review. Eur J Anaesthesiol. 2013 May;30(5):229–42. doi: 10.1097/EJA.0b013e32835d8520. PMID: 23492933. Not a handoff of interest [PubMed: 23492933] [CrossRef]

49.

Mueller SK, Yoon C, Schnipper JL. Association of a web-based handoff tool with rates of medical errors. JAMA Intern Med. 2016 Sep 1;176(9):1400–2. doi: 10.1001/jamainternmed.2016.4258. PMID: 27479693. Not a handoff of interest [PMC free article: PMC11104429] [PubMed: 27479693] [CrossRef]

50.

Nanchal R, Aebly B, Graves G, et al Controlled trial to improve resident sign-out in a medical intensive care unit. BMJ Qual Saf. 2017 Dec;26(12):987–92. doi: 10.1136/bmjqs-2017-006657. PMID: 28784841. Not a handoff of interest [PubMed: 28784841] [CrossRef]

51.

Nasarwanji MF, Badir A, Gurses AP. Standardizing handoff communication: content analysis of 27 handoff mnemonics. J Nurs Care Qual. 2016 Jul-Sep;31(3):238–44. doi: 10.1097/ncq.0000000000000174. PMID: 26845420. Background [PubMed: 26845420] [CrossRef]

52.

O'Toole JK, Hepps J, Starmer AJ, et al I-PASS mentored implementation handoff curriculum: frontline provider training materials. MedEdPORTAL. 2020;16:10912. doi: doi:10.15766/mep_2374-8265.10912. Does not measure clinical safety outcome [PMC free article: PMC7375701] [PubMed: 32715086] [CrossRef]

53.

O'Toole JK, Starmer AJ, Calaman S, et al I-PASS mentored implementation handoff curriculum: implementation guide and resources. MedEdPORTAL. 2018 Aug 3;14:10736. doi: 10.15766/mep_2374-8265.10736. PMID: 30800936. Does not measure clinical safety outcome [PMC free article: PMC6342372] [PubMed: 30800936] [CrossRef]

54.

O'Toole JK, Starmer AJ, Calaman S, et al I-PASS mentored implementation handoff curriculum: champion training resources. MedEdPORTAL. 2019 Jan 10;15:10794. doi: 10.15766/mep_2374-8265.10794. PMID: 30800994. Does not measure clinical safety outcome [PMC free article: PMC6354793] [PubMed: 30800994] [CrossRef]

55.

O'Toole JK, West DC, Starmer AJ, et al Placing faculty development front and center in a multisite educational initiative: lessons from the I-PASS handoff study. Academic Pediatrics. 2014;14(3):221–4. doi: 10.1016/j.acap.2014.02.013. Does not measure clinical safety outcome [PubMed: 24767774] [CrossRef]

56.

Odone A, Bossi E, Scardoni A, et al Physician-to-nurse handover: a systematic review on the effectiveness of different models. J Patient Saf. 2022 Jan 1;18(1):e73–e84. doi: 10.1097/pts.0000000000000701. PMID: 32433435. SR inconclusive results [PubMed: 32433435] [CrossRef]

57.

Parikh NR, Francisco LS, Balikai SC, et al Development and evaluation of I-PASS to PICU: a standard electronic template to improve referral communication for interfacility transfers to the pediatric ICU. Jt Comm J Qual Patient Saf. 2024 May;50(5):338–47. doi: 10.1016/j.jcjq.2024.01.010. PMID: 38418317. Between unit handoffs [PubMed: 38418317] [CrossRef]

58.

Price DW. Viewing resident experience with I-PASS implementation through different implementation, diffusion, and sustainability frameworks. J Grad Med Educ. 2017 Jun;9(3):321–3. doi: 10.4300/jgme-d-17-00217.1. PMID: 28638510. Design [PMC free article: PMC5476381] [PubMed: 28638510] [CrossRef]

59.

Pucher PH, Johnston MJ, Aggarwal R, et al Effectiveness of interventions to improve patient handover in surgery: a systematic review. Surgery. 2015 Jul;158(1):85–95. doi: 10.1016/j.surg.2015.02.017. PMID: 25999255. SR narrowly focused [PubMed: 25999255] [CrossRef]

60.

Riesenberg LA, Leitzsch J, Cunningham JM. Nursing handoffs: a systematic review of the literature. Am J Nurs. 2010 Apr;110(4):24–34; quiz 5–6. doi: 10.1097/01.NAJ.0000370154.79857.09. PMID: 20335686. SR outdated [PubMed: 20335686] [CrossRef]

61.

Riesenberg LA, Leitzsch J, Little BW. Systematic review of handoff mnemonics literature. Am J Med Qual. 2019 Sep/Oct;34(5):446–54. doi: 10.1177/1062860619873200. PMID: 31479296. SR outdated [PubMed: 31479296] [CrossRef]

62.

Robertson ER, Morgan L, Bird S, et al Interventions employed to improve intrahospital handover: a systematic review. BMJ Qual Saf. 2014 Jul;23(7):600–7. doi: 10.1136/bmjqs-2013-002309. PMID: 24811239. SR outdated [PubMed: 24811239] [CrossRef]

63.

Rosenbluth G, Destino LA, Starmer AJ, et al I-PASS handoff program: use of a campaign to effect transformational change. Pediatr Qual Saf. 2018 Jul-Aug;3(4):e088. doi: 10.1097/pq9.0000000000000088. PMID: 30229199. Does not measure clinical safety outcome [PMC free article: PMC6135553] [PubMed: 30229199] [CrossRef]

64.

Rosenthal JL, Doiron R, Haynes SC, et al The effectiveness of standardized handoff tool interventions during inter- and intra-facility care transitions on patient-related outcomes: a systematic review. Am J Med Qual. 2018 Mar/Apr;33(2):193–206. doi: 10.1177/1062860617708244. PMID: 28467104. SR broadly focused [PubMed: 28467104] [CrossRef]

65.

Ryan JM, Simiceva A, Eppich W, et al End-of-shift surgical handover: mixed-methods, multicentre evaluation and recommendations for improvement. BJS Open. 2024 Mar 1;8(2). doi: 10.1093/bjsopen/zrae023. PMID: 38568851. Background [PMC free article: PMC10989866] [PubMed: 38568851] [CrossRef]

66.

Ryan SL, Logan M, Liu X, et al Long-term sustainability and adaptation of I-PASS handovers. Jt Comm J Qual Patient Saf. 2023 Dec;49(12):689–97. doi: 10.1016/j.jcjq.2023.07.007. PMID: 37648628. Does not measure clinical safety outcome [PubMed: 37648628] [CrossRef]

67.

Sadri A, Dacombe P, Ieong E, et al Handover in plastic surgical practice: the ABCD principle. European Journal of Plastic Surgery. 2014;37(1):37–42. doi: 10.1007/s00238-013-0892-6. Does not measure clinical safety outcomes [CrossRef]

68.

Schmidt T, Kocher DR, Mahendran P, et al Dynamic pocket card for implementing ISBAR in shift handover communication. Stud Health Technol Inform. 2019 Sep 3;267:224–9. doi: 10.3233/shti190831. PMID: 31483276. Does not measure clinical safety outcomes [PubMed: 31483276] [CrossRef]

69.

Scott AM, Li J, Oyewole-Eletu S, et al Understanding facilitators and barriers to care transitions: insights from project ACHIEVE site visits. Jt Comm J Qual Patient Saf. 2017 Sep;43(9):433–47. doi: 10.1016/j.jcjq.2017.02.012. PMID: 28844229. No intervention of interest [PubMed: 28844229] [CrossRef]

70.

Shahian D. I-PASS handover system: a decade of evidence demands action. BMJ Qual Saf. 2021 Oct;30(10):769–74. doi: 10.1136/bmjqs-2021-013314. PMID: 33893212. Background [PubMed: 33893212] [CrossRef]

71.

Shahian DM, McEachern K, Rossi L, et al Large-scale implementation of the I-PASS handover system at an academic medical centre. BMJ Qual Saf. 2017 Sep;26(9):760–70. doi: 10.1136/bmjqs-2016-006195. PMID: 28280074. Does not measure clinical safety outcomes [PubMed: 28280074] [CrossRef]

72.

Sheth S, McCarthy E, Kipps AK, et al Changes in efficiency and safety culture after integration of an I-PASS-supported handoff process. Pediatrics. 2016;137(2):e20150166. doi: 10.1542/peds.2015-0166. Between unit handoffs [PubMed: 26743818] [CrossRef]

73.

Sheth S, McCarthy E, Kipps AK, et al Changes in efficiency and safety culture after integration of an I-PASS-supported handoff process. Pediatrics. 2016 Feb;137(2):e20150166. doi: 10.1542/peds.2015-0166. PMID: 26743818. Duplicate [PubMed: 26743818] [CrossRef]

74.

Singh N, Yun C, Likhtshteyn M, et al Systematic handoffs to improve patient outcomes and resident satisfaction: a single center observational study. J Gen Intern Med. 2019 Jul;34(7):1092–3. doi: 10.1007/s11606-019-04842-w. PMID: 30734191. Not a handoff of interest [PMC free article: PMC6614243] [PubMed: 30734191] [CrossRef]

75.

Skaret MM, Weaver TD, Humes RJ, et al Automation of the I-PASS tool to improve transitions of care. J Healthc Qual. 2019 Sep/Oct;41(5):274–80. doi: 10.1097/jhq.0000000000000174. PMID: 31483392. Does not measure clinical safety outcome [PubMed: 31483392] [CrossRef]

76.

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 Dec;80(12):1094–9. doi: 10.1097/00001888-200512000-00005. PMID: 16306279. Design [PubMed: 16306279] [CrossRef]

77.

Starmer AJ, O'Toole JK, Rosenbluth G, et al Development, implementation, and dissemination of the I-PASS handoff curriculum: a multisite educational intervention to improve patient handoffs. Acad Med. 2014 Jun;89(6):876–84. doi: 10.1097/acm.0000000000000264. PMID: 24871238. Does not measure clinical safety outcomes [PubMed: 24871238] [CrossRef]

78.

Starmer AJ, Schnock KO, Lyons A, et al Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow. BMJ Qual Saf. 2017 Dec;26(12):949–57. doi: 10.1136/bmjqs-2016-006224. PMID: 28679836. Does not measure clinical safety outcomes [PubMed: 28679836] [CrossRef]

79.

Starmer AJ, Spector ND, O'Toole JK, et al Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. J Hosp Med. 2023 Jan;18(1):5–14. doi: 10.1002/jhm.12979. PMID: 36326255. Duplicate [PMC free article: PMC10964397] [PubMed: 36326255] [CrossRef]

80.

Stenquist DS, Yeung CM, Szapary HJ, et al Sustained improvement in quality of patient handoffs after orthopaedic surgery I-PASS intervention. J Am Acad Orthop Surg Glob Res Rev. 2022 Sep 1;6(9). doi: 10.5435/JAAOSGlobal-D-22-00079. PMID: 36067218. Duplicate [PMC free article: PMC9447790] [PubMed: 36067218] [CrossRef]

81.

Tam P, Nijjar AP, Fok M, et al Structured patient handoff on an internal medicine ward: a cluster randomized control trial. PLoS One. 2018;13(4):e0195216. doi: 10.1371/journal.pone.0195216. PMID: 29672526. Duplicate [PMC free article: PMC5908079] [PubMed: 29672526] [CrossRef]

82.

Tortosa-Alted R, Martinez-Segura E, Berenguer-Poblet M, et al Handover of critical patient in urgent care and emergency settings: a systematic review of validated assessment tools. J Clin Med. 2021 Dec 8;10(24). doi: 10.3390/jcm10245736. PMID: 34945032. Design [PMC free article: PMC8707112] [PubMed: 34945032] [CrossRef]

83.

Tortosa-Alted R, Reverté-Villarroya S, Martínez-Segura E, et al Emergency handover of critical patients. A systematic review. Int Emerg Nurs. 2021 May;56:100997. doi: 10.1016/j.ienj.2021.100997. PMID: 33887611. Between unit handoffs [PubMed: 33887611] [CrossRef]

84.

Tufts LM. Response to "introduction of the EMR-integrated I-PASS ICU handoff tool". Pediatr Qual Saf. 2020 Jul-Aug;5(4):e333. doi: 10.1097/pq9.0000000000000333. PMID: 32766504. Design [PMC free article: PMC7382551] [PubMed: 32766504] [CrossRef]

85.

Tufts LM, Damron CL, Flesher SL. Addition of CORES to the I-PASS handoff: a resident-led quality improvement study. Pediatr Qual Saf. 2020 Jan-Feb;5(1):e251. doi: 10.1097/pq9.0000000000000251. PMID: 32190796. Does not measure clinical safety outcomes [PMC free article: PMC7056293] [PubMed: 32190796] [CrossRef]

86.

Walia J, Qayumi Z, Khawar N, et al Physician transition of care: benefits of I-PASS and an electronic handoff system in a community pediatric residency program. Acad Pediatr. 2016 Aug;16(6):519–23. doi: 10.1016/j.acap.2016.04.001. PMID: 27090859. Does not measure clinical safety outcomes [PubMed: 27090859] [CrossRef]

87.

Wang XL, He M, Feng Y. Handover patterns in the PACU: a review of the literature. J Perianesth Nurs. 2021 Apr;36(2):136–41. doi: 10.1016/j.jopan.2020.05.005. PMID: 33168405. Design [PubMed: 33168405] [CrossRef]

88.

Wentworth L, Diggins J, Bartel D, et al SBAR: electronic handoff tool for noncomplicated procedural patients. J Nurs Care Qual. 2012 Apr-Jun;27(2):125–31. doi: 10.1097/NCQ.0b013e31823cc9a0. PMID: 22126852. Between unit handoffs [PubMed: 22126852] [CrossRef]

89.

Wibrandt I, Lippert A. Improving patient safety in handover from intensive care unit to general ward: a systematic review. J Patient Saf. 2020 Sep;16(3):199–210. doi: 10.1097/pts.0000000000000266. PMID: 28452913. Between unit handoffs [PubMed: 28452913] [CrossRef]

90.

Yung AHW, Pak CS, Watson B. A scoping review of clinical handover mnemonic devices. Int J Qual Health Care. 2023 Sep 8;35(3). doi: 10.1093/intqhc/mzad065. PMID: 37616494. Background [PubMed: 37616494] [CrossRef]

91.

Zipursky JS, Dhhar G, Weinerman A, et al I-CATCH: a novel bundle to improve postcall morning handoffs. J Grad Med Educ. 2018 Dec;10(6):702–6. doi: 10.4300/jgme-d-18-00178.1. PMID: 30619533. Does not measure clinical safety outcome [PMC free article: PMC6314354] [PubMed: 30619533] [CrossRef]

92.

Zjadewicz K, Deemer KS, Coulthard J, et al Identifying what is known about improving operating room to intensive care handovers: a scoping review. Am J Med Qual. 2018 Sep/Oct;33(5):540–8. doi: 10.1177/1062860618754701. PMID: 29374964. Between unit handoffs [PubMed: 29374964] [CrossRef]

Appendix C. Risk of Bias Tables

Disclaimers: This report is based on research conducted by the Southern California Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 75Q80120D00003). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

None of the investigators have any affiliations or financial involvement that conflict with the material presented in this report.

The information in this report is intended to help healthcare decision makers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of healthcare services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.

This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. Most AHRQ documents are publicly available to use for noncommercial purposes (research, clinical or patient education, quality improvement projects) in the United States and do not need specific permission to be reprinted and used unless they contain material that is copyrighted by others. Specific written permission is needed for commercial use (reprinting for sale, incorporation into software, incorporation into for-profit training courses) or for use outside of the United States. If organizational policies require permission to adapt or use these materials, AHRQ will provide such permission in writing.

AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.

A representative from AHRQ served as a Contracting Officer’s Representative and reviewed the contract deliverables for adherence to contract requirements and quality. AHRQ did not directly participate in the literature search, determination of study eligibility criteria, data analysis, interpretation of data, or preparation or drafting of this report.

AHRQ appreciates appropriate acknowledgment and citation of its work. Suggested language for acknowledgment:

This work was based on an evidence report, Use of Structured Handoff Protocols for Intrahospital Within Unit Transitions, by the Evidence-based Practice Center Program at the Agency for Healthcare Research and Quality (AHRQ).

Shekelle PG, Motala A, Lawson E. Use of Structured Handoff Protocols for Intrahospital Within-Unit Transitions. Making Healthcare Safer IV Rapid Review. (Prepared by the Southern California Evidence-based Practice Center under Contract No. 75Q80120D00003). AHRQ Publication No. 25-EHC008-2. Rockville, MD: Agency for Healthcare Research and Quality. January 2025. DOI: https://doi.org/10.23970/AHRQEPC_MHS4HANDOFF. Posted final reports are located on the Effective Health Care Program search page.