Chapter 34. Handoffs: Implications for Nurses 

Mary Ann Friesen, Susan V. White, Jacqueline F. Byers 

Background

The transfer of essential information and the responsibility for care of the patient from one 

health care provider to another is an integral component of communication in health care. This 

critical transfer point is known as a handoff.1–3 An effective handoff supports the transition of 

critical information and continuity of care and treatment. However, the literature continues to 

highlight the effects of ineffective handoffs: adverse events and patient safety risks.4–11 The 

Institute of Medicine (IOM) reported that “it is in inadequate handoffs that safety often fails 

first”12 (p. 45). This chapter presents an overview of handoffs, a summary of selected literature, 

gaps in the knowledge, and suggestions for quality improvement initiatives and 

recommendations for future research. 

What Is a Handoff? 

First one needs to recognize the term “handoff” and synonymous terms that are used in a 

wide variety of contexts and clinical settings. There are a number of terms used to describe the 

handoff process, such as handover,1, 13, 14 sign-out,15, 16 signover,17 cross-coverage,18, 19 and shift 

report.20–22 For the purpose of this discussion, the term “handoff” will be used and defined as, 

“The transfer of information (along with authority and responsibility) during transitions in care 

across the continuum; to include an opportunity to ask questions, clarify and confirm”23 (p. 31). 

The concept of a handoff is complex and “includes communication between the change of shift, 

communication between care providers about patient care, handoff, records, and information 

tools to assist in communication between care providers about patient care”1 (p. 1). The handoff 

is also “a mechanism for transferring information, primary responsibility, and authority from one 

or a set of caregivers, to oncoming staff”17 (p. 1). So, conceptually, the handoff must provide 

critical information about the patient, include communication methods between sender and 

receiver, transfer responsibility for care, and be performed within complex organizational 

systems and cultures that impact patient safety. The complexity and nuance of the type of 

information, communication methods, and various caregivers for each of these factors impact the 

effectiveness and efficiency of the handoff as well as patient safety. 

Why Is There a Problem With Handoffs Today? 

As health care has evolved and become more specialized, with greater numbers of clinicians 

involved in patient care, patients are likely to encounter more handoffs than in the simpler and 

less complex health care delivery system of a few generations ago.11 Ineffective handoffs can 

contribute to gaps in patient care and breaches (i.e., failures) in patient safety, including 

medication errors,19, 24 wrong-site surgery,9

 and patient deaths.4, 7 Clinical environments are 

dynamic and complex, presenting many challenges for effective communication among health 

care providers, patients, and families.25–27 Some nursing units may “transfer or discharge 40 

percent to 70 percent of their patients every day”28 (p. 36), thereby illustrating the frequency of 

handoffs encountered daily and the number of possible breaches at each transition point. 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Our expanding knowledge base and technological advances in health care spawn additional 

categories of health care providers and specialized units designed for specific diseases, 

procedures, and phases of illness and/or rehabilitation. This dynamic, ever-increasing 

specialization, while undertaken to improve patient outcomes and enhance health care delivery, 

can contribute to serious risks in health care delivery and promote fragmentation of care and 

problems with handoffs.3, 10, 29 It is ironic that as health care has become more sophisticated due 

to advances in medical technology focused on saving lives and enhancing the quality of life, the 

risks associated with the handoffs have garnered attention in the popular press30 and reports from 

health care organizations and providers.3, 4, 6, 10, 31–35 The hazard that “fumbled handoffs”7, 10 pose 

to patient safety and the delivery of quality health care cannot be ignored. Ineffective handoffs 

can lead to a host of patient safety problems; research1

 and development of strategies to reduce 

these problems are required.33, 34

What contributes to fumbled handoffs? An examination of how communication breakdown 

occurs among other disciplines may have implications for nurses. A study of incidents reported 

by surgeons found communication breakdowns were a contributing factor in 43 percent of 

incidents, and two-thirds of these communication issues were related to handoff issues.36 The use 

of sign-out sheets for communication between physicians is a common practice, yet one study 

found errors in 67 percent of the sheets.15 The errors included missing allergy and weight, and 

incorrect medication information.15 In another study, focused on near misses and adverse events 

involving novice nurses, the nurses identified handoffs as a concern, particularly related to 

incomplete or missing information.37 

Acute care hospitals have become organizationally complex; this contributes to difficulty 

communicating with the appropriate health care provider. Due to the proliferation of specialties 

and clinicians providing care to a single patient, nurses and doctors have reported difficulty in 

even contacting the correct health care provider.38 One study found that only 23 percent of 

physicians could correctly identify the primary nurse responsible for their patient, and only 42 

percent of nurses could identify the physician responsible for the patient in their care.39 This 

study highlights the potential gaps in communication among health care providers transferring 

information about care and treatment. 

A handoff is largely dependent on the interpersonal communication skills of the caregiver33

as well as the knowledge and experience level of the caregiver. There is reported variability in 

quality,40 lack of structure in how handoffs usually occur,33 and variances in shift handoffs.22, 41–

43 Concern has been raised that the transition of care between providers during handoffs will 

continue to be problematic as research indicates that “only 8 percent of medical schools teach 

how to hand off patients in formal didactic session”3 (p. 1097), creating a large educational gap 

in new professionals and persistence of traditional models. Physicians and nurses communicate 

differently. Nurses are focused on the “big picture” with “broad and narrative”44 (p. i86) 

descriptions of the situation, whereas physicians are focused on bullets of critical information.44

A technique that seeks to bridge the gap between the different communication styles of nurses 

and physician is the situation, background, assessment, recommendation (SBAR) briefing 

model44 that is being used successfully to enhance handoff communication.45 

The issue of handoffs has become so prominent that the Joint Commission (formerly the 

Joint Commission on Accreditation of Healthcare Organizations, JCAHO) introduced a national 

patient safety goal on handoffs that became effective in January 2006.45 The national safety 

goals, developed by the Joint Commission with input from the Sentinel Event Advisory Group, 

identify new actions with the potential to protect patient safety.46 The patient safety goal requires 

2 
Handoffs—Implications for Nurses

health care organizations to “implement a standardized approach to “handoff” communications, 

including an opportunity to ask and respond to questions.”47 While the goal is simply stated, it is 

challenging to develop and implement effective strategies for handoffs across various health care 

settings, given the complexity of health care delivery. The Joint Commission’s guidelines for 

implementation of the safety goal are presented in Table 1,48 and suggested strategies for 

effective handoffs are listed in Table 2. 

Table 1. Joint Commission 2008 Hospital Patient Safety Goals Implementation Expectations for Handoffs 

1. Interactive communications allowing for the opportunity for questioning 

between the giver and receiver of patient information. 

2. Up-to-date information regarding the patient’s care, treatment and 

services, condition, and any recent or anticipated changes. 

3. A process for verification of the received information, including repeat-back 

or read-back, as appropriate. 

4. An opportunity for the receiver of the handoff information to review relevant 

patient historical data, which may include previous care, treatment, and services. 

5. Interruptions during handoffs are limited to minimize the possibility that 

information would fail to be conveyed or would be forgotten. 

Source: Adapted from Joint Commission, National Patient Safety Goals Hospital Program.48

Following are examples of each of these handoff expectations: 

1. Nurse Brown on unit A is receiving report from Nurse Green who is transferring the 

patient from unit B to unit A. The patient medication administration record (MAR) does 

not indicate the patient has received any pain medication in the past shift. When Nurse 

Brown asks about this, Nurse Green realizes she gave morphine sulfate but did not 

document it on the MAR. Due to Nurse Brown’s question, Nurse Green realizes the 

omission and communicates the information and documents it in the medical record, 

preventing an accidental overdose of a medication. 

2. A patient who had undergone a surgical procedure has not been out of bed since being 

transferred to the nursing unit. The offgoing nurse alerts the oncoming nurses that the 

patient will need help getting out of bed, possibly preventing a patient fall. 

3. Handoffs require a process for verification of the received information, including read 

back, as appropriate. For example, the receiver of the telephone message regarding a 

laboratory value is asked to write it down and read the message back, including the name 

of the patient, the test, and the test result/interpretation.49, 50 Information to be recorded 

should also include the name and credentials of sender and receiver and the date and 

time.50

Laboratory Technician: I am calling with the lab results on Mr. Green. 

Nurse: Let me get a notepad. You are calling the lab results for Mrs. Marie White? 

Laboratory Technician: No, I am calling results for Mr. Tom Green ID #12345678. 

Mr. Green’s potassium level is 5.1, which was drawn at 0700 today. 

Nurse: You reported that Mr. Tom Green’s potassium level is 5.1. This is Nancy 

Jones, RN. 

Laboratory Technician: Thank you, Nancy. That is correct; Mr. Tom Green’s 

potassium level is 5.1 This is Bill Smith, lab tech. 

4. The receiver of the handoff information has an opportunity to review relevant 

patient/client/resident historical data, which may include previous care, treatment, and 

services. A patient has been transferred, and the nurse notes several omissions from 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

4 

previous medication orders, including insulin. The nurse notifies the physician and 

obtains correct and complete medication orders, thereby avoiding a potentially serious 

medication error. 

5. A nursing unit schedules staffing coverage to accommodate the shift change and 

minimize the occurrence of interruptions during change-of-shift report. Ancillary staff 

does not leave the nursing unit until report is completed to assure phones are answered 

and timely responses to call lights are made so nurses can provide report effectively and 

efficiently. 

 
Table 2. Strategies to Improve Handoff Communication 

Strategy Example 

1. Use clear language and avoid use of abbreviations or 

terms that can be misinterpreted. 

During the reconciliation process, the nurse noted a medication that ionce daily being given every other day. The handwritten order for da

as QOD. QD and QOD are on the Joint Commission official “Do Not 

the list, “daily” should be written instead of QD and QOD should be wday.”51

2. Use effective communication techniques. Limit 

interruptions. Implement and utilize read-backs or checkback techniques. 

In the middle of a shift handoff, the unit clerk interrupts the nurse to inneeds assistance to go to the bathroom. The nurse must leave repor

find a nurse’s aide to help the patient. During this interruption, the offleave and get her son from child care. Due to the need to leave quickforgets to document and report to the oncoming nurse that a patient fchange. Efforts need to be made to ensure adequate staffing during sinterruptions. 

3. Standardize reporting shift-to-shift and unit-to-unit. The surgical unit standardized shift-to-shift handoff report with a one-

each patient, thereby providing a comprehensive, structured approacinformation on new and recovering postoperative patients. 

4. Assure smooth handoffs between settings. One of the busiest units in the hospital is the emergency department 

discharged or moved quickly out of the ED to an inpatient unit. To ennew handoff process is established that includes a phone call to the rassignment of an admission nurse so that there are no delays on the 

report so the receiving unit can prepare any special equipment, and tbetween the two nurses while viewing the patient to verify the conditiensure no changes from one setting to another. 

5. Use technology to enhance communication. Electronic 

records can support the timely and efficient transmission of patient information. 

The hospital has an electronic record and utilizes portable computers

made by the offgoing and oncoming nurse using the portable computpatient for introductions and quick visual assessment. The use of this nurse to view the patient’s plan of care, medications, and IVs at a gladuring the next shift. 

5

Source: Adapted, in part, from Joint Commission International Center for Patient Safety. Strategies To Improve Hand -Off Communica

Process to Resolve Questions. 2005.34 
Table 3. Nurse-to-Nurse Change-of-Shift Handoff Report 

Type of report Strengths cited in literature Weakness cited in literature Practice implication

reducing errors and 

Verbal report on nursing unit • Allows face-to-face interaction.41 • Allows staff to debrief and discuss situations.41 • Allows for clarification of information.41 • Can present educational opportunity for staff.41 • Verbal only—poor retention of information by receiver.55 • There may discrepancies between reported status and actual patient status.22 • May be difficult to access all relevant information41 for concise report. • Time consuming.41 • Sensory Overload.22, 75 • Augment verbal r

patient-specific focan be transferredecrease loss of 

• Use electronic su

accessible data thdate.34, 58 • Include bedside rstatus and congrupatient condition.2

• Use standardized 

transmission of es47, 55 Verbal report at the patient’s bedside • Allows face-to-face interaction.41 • Allows for clarification.41 • Nurses can assess patient together.41 • Allow the remedy of errors.41 • Involve patient.41, 52, 56 • Confidentiality issues need to be addressed.13, 41, 56 • Not all patients wish to participate in bedside report.52 • Terms (jargon) used by nurses in report may pose a concern to patients if not explained.52 • Nurses may be interrupted.41 • Monitor to assure protected, report 

• Introduce self to p• Encourage patien

patients will want and this needs to 

• Develop protocol 

handover process

• Use standardized 

transmission of es

6
7

Type of report Strengths cited in literature Weakness cited in literature Practice implication

reducing errors and 

Audiotaped report • Can be a more efficient process, 

concise53 and “less time consuming“41

• Tape may be repeated.53• Nurses who taped report can provide 

patient care while oncoming shift is listening to report.53

• May be difficult to hear or understand.41• Need access to equipment2• Question and answer interaction must 

be built into the process.47

• Sensory Overload.22• There may discrepancies between 

reported status and actual patient status.22

• Lack of educational opportunity.41• May not be current; timeliness of 

information dependent on when report was taped.41

• Need to assure th

ask questions abobetween offgoing 

• Include bedside r

status and congrupatient condition.2

• Ensure sound qua• Use standardized 

transmission of es

NOTE: Joint CommisSafety Standards reqopportunity for exchaability to ask and ans

Written report • Improvement in documentation.54

• Effective management.54• Allows oncoming shift to review 

data.54

• Question and answer interaction must 

be built into the process.47

• May be missing essential information if 

not documented.54

• Quality of documentation may vary.54

• Need to assure t

ask questions abbetween off goin

• Information also 

written report.54

• Use standardize

transmission of e

NOTE: Joint CommisSafety Standards reqopportunity for exchaability to ask and ans

Source: Adapted from O’Connell (2001), Challenging the handover ritual: recommendations for research and practice.
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

It is important to understand the context in which care is provided and be cognizant of the 

impact of the environmental processes on health care providers. The physical work environment 

may not be conducive to effective handoffs as it may be noisy58, 59 and prone to interruptions, 

(i.e., pagers, phone calls),60–63 and the handoff may be conducted under physical and emotional 

pressures.11 A study examining communication patterns among physicians and nurses found 

thirty one percent of communication exchanges involved interruption, translating into roughly 11 

interruptions an hour for physicians and nurses.60 Spencer and colleagues62 found 15 

interruptions per hour. Barriers to transmission of accurate information in a patient transfer 

include incomplete medical record, lack of complete information provided by nurses, and the 

omission of essential information.64 Handoffs are compromised if critical pieces of information 

are omitted because of difficulties with data access4, 29 or if documentation is illegible31, 33 or not 

transferred.55 Despite efforts to promote the use of electronic patient records, according to a 2002 

survey, less than 10 percent of hospitals have complete access to electronic systems such as 

computerized physician order entry (CPOE).65

The ever-increasing abundance of data requires that health care providers synthesize and 

make decisions using large amounts of complex information. Unfortunately, data quickly 

degrades; for example, critically ill patients have many clinical parameters that are being 

monitored frequently.66 Decisions need to be based on trends in the data and current information, 

which is essential to making informed decisions.66 Tremendous amounts of information are 

constantly being generated, such as monitored clinical parameters, diagnostic tests, and 

multidisciplinary assessments. When this large amount of information is combined with the 

numerous individuals—clinical and nonclinical—who come in contact with a patient during a 

treatment episode and data transmission, not all members of the health care team may be aware 

of all the information pertinent to each patient.66 

In an effort to compress information and make it manageable among health care providers, 

handoffs may result in a “progressive loss of information known as funneling, as certain 

information is missed, forgotten or otherwise not conveyed” 66 (p. 211). The omission of 

information or lack of easy accessibility to vital information by health care providers can have 

devastating consequences.4, 11 Such gaps in health care communication can cause discontinuity in 

the provision of safe care67 and impede the therapeutic trajectory for a patient. These gaps 

present major patient safety threats and can impact the quality of care delivered. 

Where Do Handoffs Occur? 

Handoffs occur across the entire health care continuum in all types of settings. There are 

different types of handoffs from one health care provider to another, such as in the transfer of a 

patient from one location to another within the hospital64 or the transition of information and 

responsibility during the handoff between shifts on the same unit.1, 41, 43 Interdisciplinary 

handoffs occur between nurses and physicians, and nurses and diagnostic personnel, while 

intradisciplinary handoffs occur between physicians3, 15, 31 or between nurses.13, 14, 41, 42,43

Interfacility handoffs occur between hospitals and among multiple organizations,68 including 

home health agencies,69, 70 hospices,71 and extended-care facilities.72, 73 

Handoffs may involve use of specialized technology (e.g., audio recorders, pagers, hand-held 

devices, and computerized records),2

 fax,73, 74 written documents,54 and oral communication.41, 75, 

77 Each type and location of handoff presents similar as well as unique challenges. Given the 

variety of handoffs, the following discussion will focus on: 

8 
Handoffs—Implications for Nurses

• Shift-to-shift handoff 

• Nursing unit-to-nursing unit handoff 

• Nursing unit to diagnostic area. 

• Special settings (operating room, emergency department). 

• Discharge and interfacility transfer handoff 

• Handoffs and medications 

• Physician-to-physician handoffs 

Shift-to-Shift Handoff 

There are paradoxes in communication and handoffs, especially at shift changes.20 Many 

human factors play a role. Human factors (ergonomics) focus on behavior and interaction 

between human beings and their environment. Human factors engineering focuses on “how 

humans interact with the world around them and the application of that knowledge to the design 

of systems that are safe, efficient, and comfortable”76 (p. 3). The handoff poses numerous human 

factors engineering implications. From the perspective of patient safety, the primary purpose of 

the shift report or shift handoff is to convey essential patient care information,14, 43, 55, 78, 79

promote continuity of care13, 41, 77, 78, 80 to meet therapeutic goals, and assure the safe transfer of 

care of the patient to a qualified and competent nurse. However, other reported purposes of shift 

report include education,41, 78, 81 debriefing,14, 41 socialization,78, 82 planning and organization,78

enhancement of teamwork,81 and supportive functions.83

The intershift handoff is influenced by various factors, including the organizational culture. 

An organization that promotes open communication and allows all levels of personnel to ask 

questions and express concerns in a nonhierarchical fashion is congruent with an environment 

that promotes a culture of safety.58 Interestingly, one study reported novice nurses seeking 

information approached those seen as “less authoritarian.”84 The importance of facilitating 

communication is critical in promoting patient safety. The shift-to-shift handoff is a multifaceted 

activity.78, 85, 86 A poor shift report may contribute to an adverse outcome for a patient.55

Handoff intricacies. A phenomenon well known to nurses is the use of nurse-developed 

notations, “cheat sheets” or “scraps” of information, while receiving or giving intershift reports. 

A study of such note taking found scraps are used for a variety of purposes, including creating 

to-do lists and recording specific information and perceptions about the patient and family.87

This approach presents some challenges, as no one else has easy access to the information; 

therefore, continuity of care may be compromised during a meal break, for example, or if the 

scrap or cheat sheet is misplaced. 

Method of shift-to-shift handoff. Handoffs are given using various methods:13, 41, 88, 89

verbally,75, 77 with handwritten notes,80, 87 at the bedside,41, 52, 56, 57, 90, 92 by telephone,91 by 

audiotape,41, 53 nonverbally,54 using electronic reports,92 computers printouts,14 and memory.14 

The strength of the bedside report method is its effort to focus on and include the patient in the 

report. There have been concerns regarding patient confidentiality,41, 52, 56, 90 which could be 

compromised if not carefully addressed. A qualitative study focused on describing the 

perceptions of patients who were present during a bedside report found some patients are in 

favor of bedside handoff, while others are not.52 Patients also expressed concern regarding the 

jargon used by nurses.52 One patient noted that including the patient in the handoff added another 

level of safety as erroneous data could be addressed and corrected.52 Case studies indicate the 

bedside handoff may be implemented for a number of reasons, including addressing specific 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

issues and improving care delivery.57, 92 A summary of the strengths and weaknesses of verbal, 

bedside, written, and taped shift-to-shift reports is included in Table 3. 

The challenge during handoffs across settings and times is to identify methods and 

implement strategies that protect against information decay and funneling,66 contributing to the 

loss of important clinical information. It is a challenge to develop a handoff process that is 

efficient and comprehensive, as case studies illustrate.57, 88, 92, 93 Observation of shift handoffs 

reveals that 84.6 percent of information presented in handoffs could be documented in the 

medical record.42 A concern that emerged in this study was some handoff reports actually 

“promote confusion,” and therefore the authors advocated improving the handoff process.42 

Another concern with handoffs is the degree to which the report is actually congruent with 

the patient’s condition. One study found 70 percent congruence between the shift report and the 

patient’s actual condition, with an omission rate of 12 percent.22 A synthesized case example of a 

psychiatric patient presents the adverse consequences for the patient if essential information is 

not communicated.94 The importance of communicating objective descriptions of the patient 

condition is highlighted. 

A study focusing on assessing the effects of manipulating information in a shift handoff on 

the receiving nurse’s care planning found in the different types of taped reports that the 

information recalled ranged from 20 percent to 34 percent.95 Another study, by Pothier and 

colleagues,55 examined different methods for transferring information during 5 consecutive 

simulated handoffs of 12 fictional patients. Three methods of handoffs were analyzed; the 

method demonstrating the greatest amount of information retention involved utilization of a 

preprinted sheet containing patient information with verbal report, followed by note taking and 

verbal report method, and lastly, only verbal report. The retained total data points for each style 

of handoff varied considerably during the five handoffs. Over 96 percent to 100 percent of 

information was retained using the preprinted sheet containing patient information and verbal 

report. Only 31 percent to 58 percent of the data were retained using the note taking style and 

verbal report.55 The verbal-only style demonstrated the greatest amount of information loss, with 

retention ranging from 0 percent to 26 percent.55 None of the data was retained using the verbalonly method for two handoff cycles. The insertion of incorrect information was observed in the 

verbal-only method. The generation of incorrect data did not occur at all during the handoff with 

the written or preprinted form style of report. This study55 supports the use of a consistent 

preprinted form with relevant patient information during shift report, with less reliance on 

verbal-only reports, in order to optimize communication. 

Nursing Unit-to-Nursing Unit Handoff 

Patients may be transferred frequently during their hospital stays.28 Yet, the patient transfer is 

fraught with potential problems and can have an adverse impact on patients.96, 97 Issues have 

been identified in the transfer handoff process, including incomplete medical records and 

omission of essential information during the handoff report.64 A number of factors that contribute 

to inefficiency during patient transfers from one nursing unit to another have been identified,97

including delay or wasted time caused by communication breakdowns, waiting for responses 

from other nurses or physicians or a response from patient placement management or bed 

control.97 Bed control involves personnel who manage the bed assignments of new and 

transferring patients. Decreasing the number of transfers is a possible strategy to decrease risks 

associated with handoffs.58

10 
Handoffs—Implications for Nurses

Nursing Unit to Diagnostic Area 

Patients are frequently sent from a nursing unit to diagnostic areas during the normal course 

of a hospitalization. Transfers have been cited as a contributor to medication errors between 

nursing units and diagnostic areas (e.g., radiology, cardiac catheterization, nuclear medicine).19 It 

is important when patients change nursing units, particularly to a different level of care, or go to 

a procedure in another department that there is clear, consistent communication and that the 

receiving area staff have the information they need to safely care for the patient.34 Complexity of 

the patient’s condition may require that the nurse caring for the patient actually accompanies the 

patient to the new setting. 

Special Settings 

Operating room and postanesthesia. Several special handoff situations occur in certain 

hospital settings. The operating room (OR) is considered “one of the most complex work 

environments in health care”98 (p. 159), with a reported mean of 4.8 handoffs per case. Nursing 

staff average 2.8 handoffs per case, with a range of one to seven handoffs.98 

There have been at least 615 wrong-site surgeries reported to the Joint Commission between 

1995 and 2007.99 To help prevent wrong-site surgery, the Joint Commission developed the 

Universal Protocol for Preventing Wrong Site Surgery, Wrong Procedure, Wrong Person 

SurgeryTM.

100, 101 It is based on the consensus of experts and endorsed by more than 50 

professional organizations.100 Effective interdisciplinary communication is critical. For example, 

a health care organization using a perioperative briefing process reported that no wrong-site 

surgeries have occurred since the adoption of the interdisciplinary briefings.44 

Dierkssuggests five categories for handoffs in the OR: (1) baseline metrics/benchmarks, (2) 

most recent phase of care, (3) current status, (4) expectations for the next phase of care, and (5) 

other issues such as “who is to be contacted for specific issues”102 (p. 10). The use of a team 

checklist in the OR was pilot tested in another study and found to show “promise as a method for 

improving the quality and safety of patient care in the OR”103 (p. 345). 

A study focused on OR communication processes identified a number of patterns and found 

the most common reason for communication in 2,074 episodes was coordination of equipment, 

followed by “preparedness” for surgery.104 The authors recommend increasing the use of 

automated processes to enhance process flow, especially related to “equipment management,” 

thereby helping with transmission of information in a more efficient manner.104 

Communication in handoffs is critical in all phases of care. However, a survey of 276 

handoffs conducted in a postanesthesia care unit (PACU) revealed 20 percent of postoperative 

instructions were either not documented or written illegibly.105 The nurses rated the handoffs 

from anesthesia staff as “good” in 48 percent of cases, “satisfactory” in 28 percent, and “bad” in 

24 percent.105 A number of suggestions for improving the quality of the postanesthesia care unit 

handoff protocol were presented including the need to communicate information verbally to the 

nurse.105

Emergency department. A study of five emergency departments (EDs) revealed that there 

were differences in the characteristics of handoffs among the EDs studied, but “nearly universal” 

attributes of handoffs were also noted.106 The researchers developed a conceptual framework for 

addressing handoffs in the emergency setting. The handoffs were not one way communication 

processes as both the offgoing and oncoming providers were engaged in interactive handoffs. 106

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

According to Behara and colleagues,106 8 of 21 handoff strategies used in other industries2 were 

observed “consistently” in the ED setting, while four were used less often and nine were not or 

rarely used. The handoff in the ED setting is viewed as a “rich source for adverse events”17 (p. 1). 

There are inherent risks in handoffs, but it was also noted that the handoff can provide the 

opportunity for two health care providers to assess the same situation and identify a “previously 

unrecognized problem”17 (p. 2). 

Studies focused on emergency nursing handoffs highlight unique aspects of this 

process.107, 108 Currie reported in a survey of 28 ED nurses that the top three concerns nurses had 

with handoffs were missing information, distractions, and lack of confidentiality.108

Recommendations included the development of guidelines to improve the handoff process in the 

ED. 

Discharge and Interfacility Transfer Handoff 

Handoffs from one facility to another occur frequently between many different settings.68–

70, 71, 72, 73, 109–111 Handoffs take place between hospitals when patients require a different level of 

care. The usual interfacility handoffs are between hospitals and long-term care facilities, 

rehabilitation centers, home health agencies, and hospice organizations. The factor that tends to 

make these handoffs challenging is gaps and barriers to communication among these 

agencies.68, 111, 112 Handoffs between facilities are also impacted by the cultural differences 

between the types of facility.73 Agencies are often geographically separate, requiring physical 

relocation of the patient, belongings, and paper records. Once the transfer has taken place, 

seeking additional information becomes a challenge.73

The continuity of patient care requires communication among various health care 

organizations.68, 71, 73, 110, 113–115 One problem noted is nurses in different settings have different 

perceptions about what is important to be conveyed, such as different perceptions between the 

hospital and home health care.70, 116 Another area of concern noted in transfers from hospitals to 

other health care organizations is incomplete documentation. More information was transmitted 

when a standard form to communicate information was utilized between a hospital and home 

health agency (HHA).69 The usage of referral forms varies among health care institutions.109

Rates of transmission of information differ from hospitals to HHAs69, 109, 113 and to extended-care 

facilities.72 It was found that HHAs affiliated with hospitals received more referral data than 

free-standing HHAs.113

Discharge planning forms address “the anticipation of a certain type of gap and also of an 

effort to create a bridge to permit care to flow smoothly over the gap”67 (p. 793). One example of 

the development of such a form using “a consensus process” resulted in the implementation of a 

Patient Transition Information Checklist to help improve communication between hospitals and 

nursing homes.114 Another type of form for communication of patient information among health 

care organizations was developed in Germany; however, followup revealed use of the form was 

not as widespread as anticipated because process barriers emerged, precluding users from easily 

completing and transmitting the forms.111 Development of any type of “patient accompanying 

form”111 requires numerous considerations and a balance between being comprehensive and not 

being cumbersome to use.111 There also needs to be adequate resources to allow health care 

providers to retrieve necessary data and transmit patient information between agencies.111 

Inadequate discharge planning has been implicated in adverse outcomes of patients.117, 118, 119

A study of 400 patients found 76 patients incurred an adverse outcome after discharge from the 

hospital. The researchers reported “ineffective communication contributed to many of the 

12 
Handoffs—Implications for Nurses

preventable and ameliorable adverse events”119 (p. 166). The most frequent type of adverse event 

was related to medications. The implications of this study indicate the need to enhance 

communication in the handoff between the hospital and posthospital care. Suggested potential 

strategies to improve the handoff include discharge planning and education of patients related to 

medications prior to discharge.119 

A number of contributors to a failed handoff in the discharge planning process have been 

identified, including, lack of knowledge about the discharge process,117 lack of time,117 lack of 

effective communication,119, 120 patient and family issues,117, 120 system issues,120 and staffing 

issues.117, 120 Communication issues have emerged as a potential contributor to readmissions.121

An ineffective nursing handoff has been identified as a contributor to miscommunication within 

the discharge process.122 The improvement of discharge planning requires that emphasis be 

placed on collaboration and interdisciplinary communication.112 Well-orchestrated discharge 

planning is recommended to help improve patient safety123 by controlling the risk of gaps 

occurring in the discharge process and its inherent handoffs. 

Handoffs and Medications 

Medication errors are considered preventable events.124 Handoff issues (e.g., transfer, shift 

change, cross-coverage) have been identified by the United States Pharmacopeia (USP) through 

its MEDMARX® reporting program as a contributing factor to medication errors within health 

care organizations.19, 24 

Incomplete transfer of medication information is recognized as a possible contributor to 

patient safety problems as patients are discharged from the hospital.119, 125 Reasons for 

medication handoff failures include incomplete patient education and the “inability of 

ambulatory care providers (including nursing homes) to receive discharge medication 

information”126 (p. 93). Medication changes during the transition (handoff) from hospital to 

skilled nursing facilities were identified as a cause of adverse drug events in a New York 

study.127 One study reported patients who received medication information and counseling 

demonstrated more compliance with their medication regimen than patients who did not receive 

such information.128 

There are multiple case examples of medication errors related to handoffs across the 

continuum of care.129, 130 In fact, USP has reported that 66 percent of medication reconciliation 

errors occur during the transfer or transition of a patient to another care level.130 A number of 

recommendations have been developed to improve the medication reconciliation process and 

reduce risks for patients.130, 131 In addition, medication reconciliation is a Joint Commission 

patient safety goal,47 with specific requirements for the process.47, 132 

Physician-to-Physician Handoffs 

Studies conducted to better understand physician-to-physician handoffs31, 33 may have 

implications for nurses. Poor handoffs included omissions of essential information such as 

medications, code status, and anticipated problems.31 Other issues contributing to failed 

communication processes included lack of face-to-face interaction and illegible documentation.31

The weaknesses identified in another handoff study included incomplete and or illegible 

information, difficulty accessing clinical information quickly, communication failures, and 

difficulty contacting other doctors.33 Strategies to address handoff problems include providing 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

legible, accurate, relevant, comprehensive information and the use of a face-to-face report.31

Suggestions for improvement include development of a process to enhance transmission of 

information, for example, the adoption of templates; use of technology; use of communication 

processes such as SBAR, education, and evaluation of handoffs;31 and a standardized handoff 

process.33

Evidence-Based Practice Implications—Handoffs for 

Today’s Health Care Environment 

The Australian Council for Safety and Quality in Health Care evaluated 777 papers for 

possible inclusion in a literature review on handoffs.1 A total of 27 papers met the inclusion 

criteria, but it was reported that “no best practice” (p. 2) existed related to systems emerged in 

the search—although a number of recommendations were provided for systems, organizational, 

and individual factors.1

 Handoffs are an extremely complex phenomenon to study as they occur 

in a variety of settings; stages along the continuum of care; and among various personnel with 

different skill sets, priorities, and educational levels. 

Contributors to handoff problems included failed communication,4, 5, 6, 7, 10, 31 omissions,31, 64, 

108 distractions,108 lack of or illegible documentation,31, 33, 73 lack of utilization of transfer 

forms,69 incomplete medical records,64 lack of medication reconciliation,129, 130 and lack of easy 

accessibility to information.6, 33, 73 A variety of environmental issues emerged—including 

designs28, 58—that served to increase, rather than decrease, the number of handoffs. Interfacility 

handoffs posed a number of challenges, including cultural differences73 and lack of integrated 

systems, thereby increasing the likelihood of transmission difficulties between organizations. 

Organizational and system failures or lack of systems to support the handoff process emerged as 

contributors to adverse events.4, 6, 7, 10 A lack of knowledge was found regarding effective handoff 

processes,117 and education on effective handoff strategies was also lacking.3, 117 Handoff 

processes need to include consideration of the person involved in the handoff and their level of 

education, expertise, and comprehension (e.g., the novice nurse’s informational needs may be 

different from the expert nurse).41 Novices also differ from expert nurses in their use of 

information.84

There must be an organizational commitment to the development and implementation of 

systems that support effective handoffs as well as a just culture.133, 134 This includes cultures of 

safety and learning.134 A safety culture supports identifications of problems and errors to be 

addressed to prevent the recurrence.134–136 A culture of learning promotes learning from the 

experiences of the past to prevent a recurrence of tragic fumbled handoffs. Environments and 

processes need to be designed to promote desired outcomes76 and enhance patient safety.137

Electronic Support of Handoffs 

A number of reports and studies have called for systems that allow ease of access to accurate 

information to improve handoffs.6, 10, 15, 29, 89, 138 Electronic technology requires that design issues 

be considered and adequate resources be allocated for successful implementation and 

acceptance.139 Research of computerized support for physician handoffs suggests this is a 

strategy that merits further consideration and evaluation.16 A study at two hospitals reported the 

implementation of a computerized system for resident handoff enhanced delivery of care and 

decreased the number of patients missed on rounds.138 There have been limited studies on 

14 
Handoffs—Implications for Nurses

computerized clinical documentation systems (CDS) in the nursing shift handoff. One study 

reported nurses perceived shift-to-shift handoffs more positively after the implementation of the 

CDS.140 Access to a physician computerized sign-out was rated positively by nurses and was 

reported to improve communication.141

Decrease Transfers of Patients 

Decreasing the number of patient transfers may reduce the risks that occur during handoffs.58

It has been suggested that “many patient transfers could be prevented by altering facility designs 

and nursing care models found in acute care hospitals”97 (p. 163), thereby decreasing the need for 

handoffs. The implementation of “acuity-adaptable rooms” demonstrated a 90-percent decrease 

in patient transports; the same study also reported a decrease in medication errors of 70 percent.28

More research of this strategy is recommended.58

Effective Handoff Process

A recurrent theme observed in the handoff literature is the need to convey essential 

information to the oncoming shift or provider. A standardized process to guide the transfer of 

critical information has been recommended.33, 34, 45, 48, 108 The use of protocols that include the 

use of phonetic and numeric clarifications are important in helping convey information 

accurately.11, 136 The Sentara health care organization adopted behavior-based expectations to 

improve the handoff process and used tools including the five Ps (patient/project, plan, purpose, 

problems, and precautions).136 It reported a 21-percent increase in effective handoffs.142 A 

medical center using SBAR in the handoff process reported less missing information in handoffs 

after implementation of SBAR.45 The use of protocols such as safe practice recommendations 

related to reconciling medications131, 132 and communicating critical test results49, 50 should be 

used in designing strategies for more effective handoffs. Some hospitals have reported 

developing strategies to improve the communication between the hospital and other 

providers.44, 71, 73, 74, 114 A summary of problems and barriers with handoffs observed in this 

review of literature are presented in Tables 4, 5, and 6. Strategies that have been reported in the 

literature are also included in the tables; however, more research is needed to identify evidencebased guidelines. The Evidence Table at the end of this chapter presents a summary of selected 

sources addressing handoffs. 

Human Factors 

The study of human factors engineering is currently being used to improve patient safety,76

and there are an increasing number of strategies and tools that can be used to design systems in a 

manner to decrease adverse outcomes. Designs to promote patient safety should include 

integration with “forcing” functions to prevent errors. However, there needs to be testing of 

proposed solutions to assure validity of these tools in the health care environment.76 Lessons 

learned from other industries are fostering the adoption of human factors principles and 

increasingly being used in health care.44, 137, 143–146 

Studies of handoffs in other industries have been analyzed for possible implications for 

health care. Patterson and colleagues2

 analyzed data from four studies147–150 and described 21 

handoff strategies. According to their findings, strategies that could be applied to shift handoff 

15 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

16 

included interactive questioning, face-to-face handoff, forcing functions such as passing a pager 

to initiate handoff to the oncoming nurse to indicate an unambiguous transfer of responsibility, 

flagging critical information, and reduction of interruptions.2 The researchers note a question 

remains “if the strategies can be generalized to health care”2 (p. 132), and call for additional 

research in this area. 

Research Implications 

Following are suggested questions for future research: 

• What are the best systems designs to reduce unnecessary handoffs? How can they best be 

implemented? 

• What are best strategies for handoffs in various settings (i.e., nurse to nurse, unit to unit, 

agency to agency, physician to nurse)? 

• What are the most effective strategies, instruments, and tools to employ to assure 

maximum transfer of and receipt of accurate, relevant, up-to-date information? 

• How can electronic technology best be deployed to support and enhance effective 

handoffs, decrease errors, and improve patient safety and patient outcomes? 

• What are the best techniques for assuring critical information is forwarded and not 

omitted or overlooked when received? 

• How can handoff contributors to medication errors be addressed and decreased? 

• What are the critical data elements that should be transferred by type of service, specialty, 

profession, and setting? 

Basic to the provision of quality health care is the ability to communicate with one another 

and safely handoff patient care in a seamless manner so every patient can benefit from each 

phase of care through a well-executed handoff. This is a process that is ubiquitous but also a 

high-risk endeavor in many settings. More research is needed in this critical patient safety arena 

to promote interdisciplinary approaches to patient safety throughout the continuum of care. 
Table 4. Factors, Problems, and Strategies Cited in the Literature 

External & internal factors that contribute to errors 

Problem/barrier associated with patient safety issues 

Practice implications (strategies for reducing errors and improving safety)

Handoff communication

Language problems may contribute to problems during handoffs in several ways. Different dialects, accents, and nuances may be misunderstood or misinterpreted by the nurse receiving report. Abbreviations and acronyms that are unique to certain settings may be confusing to a nurse working in a different setting or specialty. Medications may have similar sounding names, increasing risk for confusion. 

• Face-to-face handoff is preferred31, 35 to allow 

verbal and nonverbal exchanges and interactive 

communication and questions.47, 48

• Standardize forms, checklists, or tools (customized 

as agreed to by clinicians for specific practice areas) so that all users will understand the information from the same context.34

• Allow opportunity for questions and clarification 

during the handoff.2, 34, 47, 48

• Use a “read back” “repeat back” to decrease 

communications errors.34, 47, 49 

• Use phonetic and numeric clarifications.136• Verify information.47• Implement safe practice recommendations for 

communicating critical test results50

• Speak in simple, clear, straightforward manner and 

be specific in description of patient and situation.34

• Avoid the use of abbreviations and jargon, which 

may not be understood.34, 151

• Provide definition of ambiguous terms. • Allow receiver of handoff to review relevant 

summary and data (history, treatments, and services) and current information.48

• Allow for oncoming and offgoing clinicians to 

assess situation.35 

• Include anticipated problems or changes in 

report.31

Distractions Situational factors during a handoff can 

contribute to distractions. • Provide handoff in a location/environment that minimizes distractions.157 

Interruptions Interruptions are reported to occur frequently in 

the health care setting. • Limit and discourage interruptions.2, 4, 34, 48, 108 and provide coverage of other duties during handoff to 

support focused transition 

17
18

External & internal factors that contribute to errors 

Problem/barrier associated with patient safety issues 

Practice implications (strategies for reducing errors and improving safety)

Noise Background noises such as pagers, phones, 

overhead paging, equipment noise, alarms, and talking contribute to increased difficulty in hearing report and can lead to inaccurate interpretation of information. 

• Provide handoff in a location/environment that 

allows those involved in the handoff to clearly hear the information.3

• Use a “read back” to decrease communications 

errors.47, 49 

• Use phonetic and numeric clarifications.136

Fatigue Increased errors are noted in nurses working 

prolonged shifts. 

• Limit the amount of hours worked to reduce fatigue 

and errors associated with fatigue.58, 153, 154, 155

Memory Short-term memory is limited and lapses may 

occur when large amounts of information are communicated during a handoff. 

• Design systems to reduce reliance on memory.76, 157• Use preprinted patient information forms for 

accuracy and completeness of information in handoff.55

• Provide health care providers with access to data 

to reduce reliance on memory in handoff.55, 157

Knowledge/ experiences in handoffs 

Novice nurses and expert nurses have different needs.158

Novice nurses may encounter issues with handoffs. Novice nurse may need supplemental information during the handoff. Staff may not have been educated on strategies for an effective handoff and discharge planning. 

• Support novice nurses with orientation and 

preceptor programs. 

• Provide continuing education programs on effective 

handoff strategies.45

• Provide experienced consultants to lessexperienced nurses as they may not have skills in 

their repertoire for advanced problem-solving.37, 84

• Provide comprehensive, pertinent information, but 

avoid overload during handoff.78

Written communication Trying to interpret illegible notes from another 

provider may create errors in communication. 

• Use electronic strategies to decrease problems 

with illegibility.159

• Use standardized processes (customized to a 

clinical area, practice setting) to assure critical information is communicated in handoff.34, 35
19

External & internal factors that contribute to errors 

Problem/barrier associated with patient safety issues 

Practice implications (strategies for reducing errors and improving safety)

Variation in processes There may be wide variance in the way a 

handoff is conducted that may lead to omission of critical information and contribute to medical and medication errors. 

• Adopt a standardized, consistent approach to the 

handoff to decrease errors.33,34

• Adopt and use behavior-based expectations to 

reduce risks and promote patient safety. Tools to use during handoffs include the 5 Ps for Patient/Project, Plan, Purpose, Problems, Precautions136 and Situation, Background, 

Assessment Recommendation (SBAR).34, 44, 45

• Communicate essential patient care information.34• Develop and implement a systematic process for 

the reconciliation of patient’s medications to decrease risk associated with transfers and transitions to other levels of care.130, 131, 132

Table 5. Issues, Problems, and Strategies Cited in the Literature Organizational/system issues that contribute to errors 

Problem/barrier associated with patient safety issues 

Practice implications ( strategies for reducing errors and improving safety)

Culture In a culture that lacks sufficient focus on safety 

and learning, staff may be reluctant to report problems or may not feel comfortable asking questions. 

• Support the development of a culture of safety 

where reporting of errors and problems is accepted and encouraged.58, 133, 134 

• Encourage the development of a “learning 

culture”134 and a “just culture.”133, 134

2

Hierarchy Hierarchical structure may impede open 

communication. The nurse may not feel comfortable asking questions to clarify information or may feel intimidated. 

• Promote culture of safety where open 

communication is supported.58, 160, 161 

• Develop protocols or policies that support a culture 

of respect, collaboration, and collegiality among all nurses and health care providers.161

• Provide education for all health care providers on 

effective communication strategies such as the use of SBAR (situation, background, assessment and recommendation) to enhance communication.44, 45, 144

AC2

2

W
20

Organizational/system issues that contribute to errors 

Problem/barrier associated with patient safety issues 

Practice implications ( strategies for reducing errors and improving safety)

Systems support Lack of time to access information and 

complete report will reduce time for questions and answers. 

• Assure that there is time to complete the handoff 

report. 

• The receiving health care provider needs to have 

access to pertinent, accurate, timely patient information.34, 48

• Recognize that a handoff requires the opportunity 

for interactive questions and answers.34, 48

• Develop systems that support efficient operations in 

the retrieval of data in a timely manner to allow updated, current, accurate information to be provided to the receiver of the handoff.34, 138, 141 

J

J

S2

V

Infrastructure There may be inadequate staff, tools, or 

equipment for effective handoffs. • The leadership needs to promote the design and implementation of systems within an environment to 

provide safe patient care.58

• Provide adequate human resources, equipment, 

technology, and educational opportunities to promote optimal handoffs.58

• Involve nurses in the design of work 

environments.58

2

Transfer of patients(within health care organization)

Increased number of transfers increases the need for handoffs. • Consider health care delivery design models in which patient transfers are minimized.28

• Include nursing staff in the design of handoff 

processes.58

2

Physical space limitations for handoffs 

Environment may not be conducive to conducting a handoff (interruptions, noisy). • Include health care providers in the design of work environments so adequate space requirement and 

configurations are identified. 

2

Technology limitations and use of manual reports and records/ difficulty accessing essential information 

Lack of technology may create voluminous paper records (medication records, lab reports) with multiple reports to be referenced for handoffs to another unit, setting, or facility. 

• Design electronic systems that support the easy 

retrieval of accurate and timely data.34, 141, 163 

• Provide for adequate planning processes, 

infrastructure, human resources, and education to successfully implement electronic support.139, 162

AJ

S2V

Different cultures or organizations 

Organizations may have different goals, focus, and resources. 

• Develop processes between sending and receiving 

organizations to assure both organizations are aware of requirements for handoff.44, 73 

• Plan resource allocation to meet the patient 

needs.44
21

Organizational/system issues that contribute to errors 

Problem/barrier associated with patient safety issues 

Practice implications ( strategies for reducing errors and improving safety)

Intra- or extra-system transfers 

Transfers to a setting/facility within a single system may create fewer problems than a transfer to a different system/health care provider in which different forms and technologies are used. Transfers require efforts to assure continuity of care as the patient transitions to another level of care. 

• Seek to design systems, processes, and policies 

that allow for collaboration and efficient transfer of essential information between organizations during handoff.68, 69, 73, 111, 112, 115 

• Complete medication reconciliation process.129, 132 • Remove barriers to communication. • Assure a bidirectional communication process 

between health care providers.110

• Communication involves verbal, written, and 

electronic means. 

• Monitor process for opportunities for improvement.44

AACC

2JSW2

Staffing limitations Staffing shortages may contribute to gaps in 

transmission of information in handoff. • Allocate adequate human resources to support handoffs and meet patient care needs/functions.58, 111 

2

S

Equipment failures A number of devices are used in a handoff. 

Critical information may not be transmitted if electronic devices fail. 

• Follow up on critical information to assure it was 

received.2

• Monitor, replace equipment, supplies to reduce 

contributors to communication failures.53 

• Upgrade equipment to improve communication 

processes.2

Lines of responsibility Persons entering into a handoff situation may 

not be clear on when responsibility of patient/situation is transferred, which can lead to a “fumbled” handoff, if the responsibility for 

care of patient and of followup is not clearly delineated. 

• Use a forcing function2, 44 to indicate the transfer of 

responsibility such as by passing a pager indicating that the receiving nurse is accepting responsibly for the patient and confirming the transfer of responsibility.2, 

• Unambiguous transfer of responsibility.2• Clearly define responsibility at transition.4

Tight time constraints Time constraints during handoffs (e.g., pressure 

to increase patient flow across the system) may contribute to a report that is rushed and incomplete. 

• Assure there is time for interaction and question and 

answer during a handoff.34

• Allow receiver of information to review relevant 

information.48

JJ
22

Special Issues 

Problem/barrier associated with handoff 

Practice implications (strategies for reducing errors and improving safety) Re

Emergency situations/critical activities 

Handoffs in a critical situation present a number of challenges. • Remain for the completion of handoff until it is clear that critical information has been received 

and the transfer of responsibility has occurred by the accepting health care provider team.35

• It may be necessary to delay handoff in critical 

situation to assure concerns are addressed.2,4 35 

• Exercise caution and situational awareness in 

emergency situations to assure all information is transmitted and received and continuity of care is provided.4

BePa

Si

Code status Code (Do Not Resuscitate (DNR)) status 

may be omitted from handoff report and not documented in medical record, or information may not be accessible. 

• DNR status needs to be documented and 

communicated so members of the health care team are aware of status.164

• Communicate code status in handoffs.31, 164

Ar

Go

Critically ill or labile patient Offgoing and oncoming shifts may 

perceive patient situation differently, and the patient situation may change during the actual shift transition. 

• Bedside report, walking rounds afford both the 

offgoing and oncoming shifts the opportunity to observe the patient together; address and problem-solve together; clarify issues; answer questions; and assure continuity of care.17, 22, 35

Pe

Ri

Si

Variable resources on, off shifts 

Transfer handoff may occur after normal business hours when resources are less available, increasing the possibility information will be omitted. 

• Assure critical information is documented and 

transmitted. In addition allow for an interactive report so that questions can be answered and issues addressed.44

• Assure that all medication information is 

documented for the receiving facility. 

• Reconcile medications.129, 130, 131, 132• Design “forcing functions” to reduce ambiguity 

and confirm acceptance of assignment.2, 44

• Coordinate adequate staff coverage to support 

patient care handoffs.44

• Communicate to and confirm acceptance of 

transfer and allow exchange of essential information.35, 44

IS

JoCe20

Le

Pa

SiUS

Table 6. Issues, Problems, and Strategies Cited in the Literature 
Handoffs—Implications for Nurses

Search Strategy 

To retrieve pertinent literature on the topic of handoffs, the following databases were 

reviewed: Academic Search Premier, CINAHL, Pre-CINAHL, EMBASE, Ovid’s Medline, 

PubMed, and PsychInfo. The databases were searched for variants of the words “handover” and 

“handoff,” “shift report,” and “changeover.” Additionally, the databases were searched for 

groups of subject terms representing the concepts of patient transfer, communication, and 

continuity of care. The use and combination of subject headings varied depending on the 

characteristics of each database. Searches for the concept of patient transfer used the following 

subject headings: transfer, discharge; transfer, intrahospital; patient discharge; transportation of 

patients; and patient transfer. The concept of communication was represented by terms such as 

“communication barriers,” “communication,” “communication skills,” “communication theory,” 

and “interpersonal communication.” Subject headings focusing on the concept of overall health 

care delivery or quality included quality of care, health care delivery, continuity of patient care, 

patient safety, and medical care. 

Acknowledgment 

The authors wish to acknowledge Stephanie Narva Dennis, M.L.S., for support and 

assistance in conducting the literature search. 

Author Affiliations 

Mary Ann Friesen, M.S.N., R.N., C.P.H.Q. Program Manager, Center for American Nurses, 

Silver Spring, MD 20910-3492. E-mail: mary.friesen@centerforamericannurses.org. 

Susan V. White, Ph.D., R.N., C.P.H.Q., F.N.A.H.Q. Associate Chief Nurse, James A. Haley 

Veterans’ Hospital, Tampa, FL 33612. E-mail: Susan.White4@va.gov. 

Jacqueline F. Byers, Ph.D., R.N., C.N.A.A., C.P.H.Q. Professor, College of Nursing, 

University of Central Florida, Orlando, FL 32816-2210. E-mail: jbyers@mail.ucf.edu. 

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30 
Evidence Table. Selected Sources on Handoffs—Nursing Handoffs, Quality Improvement Activities, Interdisciplina

Source 

Safety issue related to practice 

Type Study outcome 

measures 

Setting & study population Intervention Key fin

Anderson & Helms 199369

Handoff between hospital and home health agency (HHA) 

Descriptive retrospective study 

Inventory Referral Information (IRI) 40 items. Score 0–40 Monitor type, amount of information the HHA received from the hospital 

Illinois, Iowa 300 patient records 1988–1990 Referrals of 6 hospitals to 4 HHAs 

No intervention • Scor

item

• Hosp

recenona

• More 

betwwhe

Atwal 2002122 Discharge planning Qualitative Interview of nurses utilizing critical 

incident technique Observation of nurses and other health care providers 

19 nurses Interviewed Observation at multidisciplinary meetings 

No intervention • Misc

infor

• Obs

precmult

• Stra

relat

Australian Council for Safety and Quality in Health Care 20051 

Handoffs Literature review Retrieval of literature 

that addresses handover and safety in both health and nonhealth literature The literature review report includes sources from 1993–2004. 

777 papers reviewed Only 27 met inclusion criteria 8 non-health care 19 health care Another 21 papers did not meet criteria but were termed useful. 

Studies with interventions reviewed included computerized documentation system, interdisciplinary rounds, Other reports included observational studies cases studies 

• Qua

handpoor

• Majo

stud

• Thre• Syst

pape

• Orga

pape

• Indiv• Reco

the tprov

31
32

Source Safety issue related to practice Type Study outcome measures Setting & study population Intervention Key finBruce & Suserud 2005107 Experiences of emergency nurses receiving patients who are attended by ambulance nurses Qualitative descriptive Four themes were identified: prehospital reporting, symbolic handover, ideal handover, nonideal handover. Sweden 6 nurses No intervention Analyze experiences of emergency nurses and the handover and triage process 

• Rep

ambeme

• Inter

and 

• The 

“the to be unifo

• The 

descpatieprob“clea

• Auth

be a

Behara 2005106 Emergency department (ED) 

transitions 

Qualitative ethnographic 

Observation of shift changes, and additional types of exchanges and investigations. Content analysis and grounded theory. Development of conceptual framework. 

United States and Canada 5 EDs: 3 inner city 1 private tertiary center 1 community 

No intervention • Varie

obse

• “Nea

ED h

• Con

inclu

1. 2. 3. 4. 

Cahill 199852

Bedside handoff (patient perceptions) 

Qualitative design using a grounded theory approach 

Three major categories emerged from the interviews with patients: • ‘Maintaining a 

professional distance’ 

• ‘Establishing 

professional sharing’ 

• ‘Maintaining 

patient safety’ 

Nursing Unit 10 patients 

 No intervention • Main

iden

• Patie

not aterm

• The 

were no lo

• Som

invoprocdid. 
33

Source 

Safety issue related to practice 

Type Study outcome 

measures 

Setting & study population Intervention Key fin

Currie 2002108

The handoff in an ED setting 

Survey/ Questionnaire 

Questionnaire addressed 12 topics in handoff (examples include; patient name & age, medical history & medications, vital signs, plan of care, and other topics.) Also included problems with handoff and preference for bedside or nurses’ station handoff. 

Emergency admissions and assessment unit. 28 nurses 

No intervention • Prob

includistrconf

• High

reastreatrestrmed

• Reco

handguid

• Sugg

handconfbriefnurshas 

Dowding 200195 Shift report Experimental factorial design Two independent variables: 

1. Type of shift 

report (retrospective, prospective) 

2. Schema-type 

information (consistent, inconsistent) 

Dependent variables: amount of information documented, recalled and the plan of care. 

Scotland Two hospitals Medical and surgical wards 48 nurses 

Manipulation of a handoff (shift report). Explore the effect of manipulating information on nurse’s care planning. The nurses were randomly assigned to one of the four experimental conditions. 

• Type 

signcare 

• Type 

signdocuno e

• Reca

20.1type 

• The 

audi“’norinter

• Furth

a mo
34

Source Safety issue related to practice Type Study outcome measures Setting & study population Intervention Key finFootitt 199791 Evaluation of a pilot of telephone method for shift report Piloting a new system Quality improvement Communications and cost effectiveness of handoff process using new telephone- based system. United Kingdom Gynecology department of hospital Sample size not specified Implementation of Nurse Communicator System (telephone system for reports) in spring 1995 • Rep

spen

• Dee• Allow

reso

• Nee

phonhand

Greaves 199990 Bedside handoff (patient perceptions) Qualitative Patients were interviewed and asked questions about the handoff process. Aspects explored included likes, dislikes, privacy, experience with past handoffs, areas for improvement. Hospital Four patients Assess patient perceptions of handoffs at the bedside No intervention • Four 

inter

1. 2. 3. 4. 

Haig 200645

Communication Quality 

Improvement 

Use of SBAR Outcome Measures

Medication reconciliation Adverse events 

Bloomington, Illinois Medical center 

Effort to implement situation, background, assessment and recommendation (SBAR) communication tool. 

• SBA

2005

• Use 

medincre

• Adve
35

Source 

Safety issue related to practice 

Type Study outcome 

measures 

Setting & study population Intervention Key fin

Hardey 200087

Communication of information 

Qualitative ethnographic 

Communication process, specifically the use of “scraps” examined. “Scraps” are “personalized recordings of information” (p. 209) on paper or in notebooks by nurses. Grounded theory analysis. 

England 5 wards (geriatric) Observation of 23 handovers Observation of interactions Interviews with 34 nursing personnel Written records 

No intervention • Scra

of pulist, aaboustatu

• Scra

augm“perc

• Thre

relatconsscraconf

Hendrich 200428 Impact of acuity- adaptable rooms 

on transfers, medical errors, satisfaction 

Pre-post method 12 outcomes-based 

questions (seven addressed in article). Outcomes studied: patient complications & mortality, sentinel events, clinician satisfaction, patient satisfaction, recruitment and retention of nurses, market impact, costs 

United States Hospital 2 years baseline data 3 years postimplementation data 

Use of acuityadaptable rooms Postimp

• 90% 

trans

• 70% 

error

• Decr

falls 

• Dec

dissa

Hopkinson 200283

Handover related to the dying patient 

Qualitative phenomenological approach 

Nurses were interviewed and asked to discuss caring for a dying patient. 

United Kingdom Two hospital trusts Eight hospital medical wards 28 nurses 

No intervention • Two 

hand

1. 2. . 
36

Source Safety issue related to practice Type Study outcome measures Setting & study population Intervention Key finKassean & Jagoo 200557 Handoff process Quality improvement project Use of force field analysis Evaluation of bedside handover using 6 criteria based on observation Perceptions of patients’ regarding bedside handoff using a 6-item, semistructured interview Mauritius 28-bed ward 10 nonparticipant observation handovers Semistructured interviews of 40 patients Implementation of bedside handoff 

• Obs

reverangindiv

• 40 p

indicwith hand

• The 

was 

Kelly 199985 Handoff process in the critical care 

unit 

Qualitative Ethnomethodological approach 

The components of the handoff were examined, including the initiation, content, the handing over to the next shift. 

Critical care unit 2 handover transcripts (2 handoffs) 

No intervention • Exam

shift interexam

• Four

obseare d

Kennedy 199954

Nonverbal handoff Qualitative Study 

Quality improvement 

Pre Non-Verbal Handoff Nonparticipant observation of bedside handoff Post nonverbal handoff Qualitative data obtained via semistructured interview of staff, Eight months post implementation of nonverbal handoff an audit of documentation was conducted 

28-bed ward 41% (9) members of nursing team Stratified sample Documentation 

The implementation of a nonverbal handoff system 

Post no• The 

inforrepoinfor

• Disa

docurepo

• Team 

hand

• How

all npassin adrepo

• Audi

a 60docuimplhand
37

Source 

Safety issue related to practice 

Type Study outcome 

measures 

Setting & study population Intervention Key fin

Kerr 200278 Shift “handover” 

(handoff) 

Qualitative The handoff was 

observed by researchers. 

An interview guide 

was used and focused on three issues: practice 

 (7 questions), 

functions (3 questions), and problems and effectiveness (9 questions). 

2 pediatric units 20 handovers per unit 12 individual per unit and 2 group interviews per unit Participants included nurses, support worker, students 

No intervention • Four 

infororga

• Thre

handpost

• A nu

idenhandtenscominforconffami

Lally 199981

Intershift handoff Qualitative 

Observation 

 Research question: To what extent does the intershift handover involve social cohesion of the group/team? Observation Audiotaped the handovers, used field notes, transcribed the data, and conducted qualitative analysis. 

United Kingdom One ward in a hospital in the 6 shift handovers 

No intervention • The 

revecatelearnus, mand 

• A nu

idenincluinforenhacohe
38

Source Safety issue related to practice Type Study outcome measures Setting & study population Intervention Key finLamond 200021 Shift report Two-by-two design comparing 2 hospitals Content analysis used on audio and written data Multidimensional scalogram analysis (MSA) of content comparing shift report and documentation Types of information in report and documentation analyzed included general, physical, physical measures (i.e., pulse, blood pressure, etc.), psychological, social, family, nursing interventions, medical treatment, global judgments, management issues. England 2 hospitals 2 medical 2 surgical wards 5 consecutive shift handoff reports on each ward, total of 20 reports Records documentation (medical notes, kardex, care plans, etc.) from 15 patients per ward, total of 60 patients No intervention • Shift 

55 maver

• Corr

inforand 0.00com2008

• Shift 

certaward

• More 

recorepo

• The 

aggrnamdiagsurg

Leonard 200444

Communication Quality 

improvement 

Patient transfer to skilled nursing facilities (SNFs), communication of data checklists, Employee satisfaction scores. Turnover Wrong site surgery 

Kaiser Permanente Implementation of 

standardized communication process (SBAR), checklists for patient transfers, briefings 

Checklis• Impr

comhosp

• Impr

corretrans

Briefing• Impr

satis

• Nurs• No w

repoimpl
39

Source 

Safety issue related to practice 

Type Study outcome 

measures 

Setting & study population Intervention Key fin

Lingard 2005103

Communication in the operating room (OR) 

Qualitative Ethnographic 

observation of implementation of checklist Informal interviews to assess the benefits and disadvantages of checklist Grounded theory approach 

OR of teaching medical center 33 OR staff ( surgeons, nurses, anesthesiologists, residents ) 18 procedures 11 interviews 

Implementation of a Preoperative Team Checklist 

• Che• Che

1–6 

• Som• Disc

effic

• Bene

inco

• 6 fun

iden

1. 2. 3. 4. 5. 6. 

Liukkonen 199377

Handoff content Content analysis 

qualitative and quantitative 

Identified type of information discussed in the shift handoff; a total of 28,891 statements were placed in 5 content classes. 

2 wards in 2 geriatric homes Audio recording of shift reports Transcripts 1,034 pages 

No intervention • Han

minu

• Mos

physfollo

Manias & Street 200086

Communication practices of nurses in a handoff 

Qualitative Critical ethnography 

Focus on issues and activities related to handoff, including nurses’ interactions. The data was analyzed using textual analysis followed by more indepth analysis using a 4-question guide 

Australia 16 bed critical care unit 6 nurses Professional journaling, observation 3 focus group interviews 2 interviews per participant 

No intervention • First 

presSeconurshandindiv

• Com

prac

• Five 

idenexamtidinand 
40

Source Safety issue related to practice Type Study outcome measures Setting & study population Intervention Key finMcKenna & Walsh 199788 Shift handoffs Action research model Four goals were identified: 1. Assess present handoff processes, trial a handoff method. 2. Complete handoffs within 30 minutes. 3. Continue care during handoff. 4. Care continuity between shifts. Australia 44 wards medical, surgical, high dependency unit, oncology/ palliative care Audit of duration of handoff and comments from the staff 

• A variety of 

handoff methods were trialed on the 4 wards. 

• Handoff 

methods included bedside, verbal and bedside, verbal by nurse in charge, verbal, tape recorded. 

• On a

decrminu

• Cha

on dthe h

• Diffe

may nursfor o

Menke 2001140 Computerized clinical 

documentation system (CDS) 

One group pretest–post-test design 

Pre- and post-test time study of nursing care /charting, medication delivery, clinical decisionmaking, documentation quality; continuity of care (shift-to-shift report) 

Pediatric intensive care unit Schedule and delivery time of medications, chart review, lab values, computer record review, and questionnaire 

Implementation of a computerized CDS 

• After 

comin timdocu

• Impr

docu

• Una

normto m“pap

• Impr

reco

• Incre
41

Source 

Safety issue related to practice 

Type Study outcome 

measures 

Setting & study population Intervention Key fin

Miller 199813 Continuity of care, types of handover 

(handoff) 

Literature review Review of articles 

addressing four types of shift handoffs: recorded, bedside, written, and verbal. Literature review included other components related to the handoff, ritual, “what to say,” and quality. 

Literature review nursing handoffs spanning a 15-year period (1983–1998) 

Literature review • The 

“rituasuggqual

• Issu

“incoin th

• Thre

prov

- F- D

c

- U

“h

O’Connell & Penney 200141

Shift handover Qualitative 

Grounded theory approach 

Assess how nursing care is 

1. determined 2. delivered 3. communicated 

in the hospital Three handoff methods were studied: 

1. face-to-face 

verbal in office 

2. face-to-face at 

the bedside 

3. tape recorded 

Teaching hospital 1.Semistructured interviews (n = 27) nurses, patients, relatives 2. Field observation (5 sites) 3. Informal interviews (n > 40 nurses) 

No intervention • Stre

idenhand

• Han

com

• Foru

and 

• Reco

devehand
42

Source Safety issue related to practice Type Study outcome measures Setting & study population Intervention Key finParker 199214 Shift handover Qualitative observation Observing the process, method, and content of handovers Critical care unit, burn unit, step down unit, medical unit, surgical units, 12 handovers No intervention • Han

minu

• A va

methhandcomnote

• Four 

1. 2. 3. 

4. 

Patterson 199564 Continuity of care during patient transfers Descriptive 59-item survey of nurses, addressing patient transfers Medical Center 197 Nurses 21 units No intervention • 68% 

rece

• 82% 

inforall u

• Critic

item

Patterson 20042 Handoffs in high- risk settings Qualitative Observation of handoffs in four 

different settings based on previous research findings; 21 handoff strategies listed 

4 studies: NASA mission control, nuclear power plant, railroad dispatch center, ambulance center 

No intervention • Han

inter

• Com

impreffecacro

• 19 h

obse
43

Source 

Safety issue related to practice 

Type Study outcome 

measures 

Setting & study population Intervention 

K

ey fin

Payne 200080

Handover Qualitative 

Ethnographic 

Observation of information exchanged in handover Audio taping of handovers Interviewed staff, Review of documentation 

England 5 wards in geriatric unit in hospital Observation 146 hours 23 handovers 34 interviews with nursing personnel Written records; Kardex, care plans, “scraps” 

 No intervention 

• Rep

laste

• Use 

abbr

• Rep• Stud

diffichand

• Thre

obse

1. 2. 3. 

*Note: r200087)

Petersen 199816 Computerized sign-out Pre- and Post- Intervention 

Quality improvement 

Patient data included sociodemographic, severity of illness, comorbidity. Outcome Measures: adverse events. 

Urban teaching hospital Boston Admissions: 3,146 baseline 1,874 Pre-intervention 3,747 intervention period 

Computerized signouts Decreas

events rimplemesign-out with the 

Priest & Holmberg 200094 

Illustration of ineffective shift report 

Qualitative Synthesized case study 

Incomplete assessment on admission, ineffective shift report, adverse drug reaction, and the consequence for patient in a psychiatric setting 

Synthesized case study 

Nursing care rendered is examined and critiqued in synthesized case study. 

• Seve

pres

• Nee

and a ha
44

Source Safety issue related to practice Type Study outcome measures Setting & study population Intervention Key finPothier 200555 Data loss in the handover Quasi- experimental Assess three methods for handoff and the differences in information retention Retention of data (total data points) Omission of data Insertion of incorrect data Hospital 5 nurses Handoffs of 12 fictional patients Type of handover 3 techniques studied : 

• Verbal only • Written—verbal 

with written notes 

• Sheet—use of 

preprinted sheet with patient information and verbal exchange at handover 

• 96% 

was preppatierepo

• 31% 

retaistyle 

• 0-26

“verb

Prouse 199553 Taped shift reports Quality Improvement 

Project 

Pilot study 

Study reported on staff description of taped recorded handover postimplementation 

Hospice nursing ward Early and late shift handovers Sample size not specified 

• Implementation 

of taped handovers 

• Evaluated at 1 

and 3 months postintervention 

• After 

repoas “owho

• Sugg

bene

• Disa

pres

Richard 198822 Congruence between patient 

condition and shift report 

Descriptive Handoff study for 

incongruence, omission, omission resulting in incongruence Data Collection of 11 items 

Western U.S. 19 medical surgical units of an 800-bed hospital 57 shift reports 584 patients 2,952 entries 

No Intervention • Disc

betwactu

• Ove

(rangpatierepo

• Ove

infor16%

• Inco

11–1

• Sign

betwlack 
45

Source 

Safety issue related to practice 

Type Study outcome 

measures 

Setting & study population Intervention Key fin

Sexton 200442

Handover shift report 

Qualitative Observation of 

handover Analysis of data from audiotaped handovers Compare handoff information with documentation Information in nursing handover categorized to where information documented 

Australia 30-bed medical unit in 200-bed hospital 23 handovers 

No intervention • Shift 

minu

• Som

repoconf

• Nurs

care sour

• 84.6

comdocu

Sidlow & KatzSidlow 2006141

Electronic sign-out system 

Descriptive Surveyed nurses 

regarding impact on nursing care after implementation of sign-out program. Likert scale survey with option for comments 

New York General medical unit, in medical center 19 nurses 

• Nurses given 

access to computerized sign-out used by physicians 

• Training • Provided with 

computer printouts and requested to use reports 

• Impl

rated 

• Nurs

comnurs

• Adva

recophys

Sherlock 199543

Handover Qualitative Observation of 

handovers and interviews of nursing students to study “quality and effectiveness” (p. 33) 

2 medical wards 3 nursing students 

No intervention • Han

minu

• Varia

hand

• Teac

hand

• Prac
46

Source Safety issue related to practice Type Study outcome measures Setting & study population Intervention Key finSpee 200093 Handover report Quality improvement Handoff shift report option trialed, staff asked to document concerns during the trial. Evaluated at staff meeting. Professional practice leader reviewed documentation on census sheets during trial period. Nursing home Two 34-bed units Introduction of a change process to the shift handoff. Nurses were provided with 6 shift report options. One option trialed for 3 weeks 

• One • Anot

subsuse. 

• Nurs

assorepodocupatie

Strange 199682 Handover report Qualitative Ethnographic analysis of the 

handover process 

One ward No intervention • Prac

are e

• Tech

incluinfor

• The 

desc

Strople & Ottani 200689

Intershift report Literature review Shift report purpose, 

methods, formats described. 

Review spans 1988–2005 63 citations 

Literature review • Anal

probcom

• Alter

comcomimpoare d
47

Source 

Safety issue related to practice 

Type Study outcome 

measures 

Setting & study population Intervention Key fin

Taylor 200284

Handover Qualitative Student nurses and 

RNs were observed conducting patient care procedures. Taped, transcribed interviews were analyzed and coded. 

Hospitals Observation and interview Three groups students year 1 students year 3 RNs 18 student (novice) nurses 15 RNs (expert) nurses 

No intervention • All s

least patie

• Sour

includocupatie

• Diffe

studacce

• Prob

encodiscu

Timonen & Sihvonen 2000165 

BedsideHandoff Descriptive Patient and nurses 

perceptions of report Participation by patients in report Identification of factors that influence patient participation 

Finland Six hospitals 118 nurses 74 patients 76 “bedside reporting session” 

No Intervention • Rep

minu

• Diffe

nursrepo

• Patie

reasrepoand parti

Webster 199956

Bedside handoff Action Research 

Quality improvement 

Questionnaire used at 3 and 6 months postimplementation. 3 months: 13 questions; 6 months: 9 questions. Access to information, patient/client orientation, confidentiality, communication (quantitative & qualitative) 

Medical unit 3 months: 22 surveys 6 months: 24 surveys 

Change from traditional handover to bedside handover. 

6 month • 100% 

resu

• 92% 

patie

• 58% 

acceenou

• 21% 

discuconc

• 67% 

com
48

Source Safety issue related to practice Type Study outcome measures Setting & study population Intervention Key finVan Eaton 2005138 Computerized sign-out Randomized crossover Observation Self-reported Patients missed in rounds Time spent in rounds Assessment of intervention on continuity of care 16-question survey administered three times to assess continuity of care. 2 teaching hospitals 14 resident teams 6-surgery 8-medicine 161 residents Computerized sign- out system • Decr

on ro

• Decr

roun

• The 

an imcare