Educational interventions to improve handover in health care: a systematic review

Educational interventions to improve handover inhealth care: a systematic reviewMorris Gordon1,2 & Rebecca Findley2

CONTEXT Effective handover within thehealth care setting is vital to patient safety.Despite published literature discussing strate-gies to improve handover, the extent to whicheducational interventions have been used andhow such interventions relate to the publishedtheoretical models of handover remain unclear.These issues were investigated through asystematic review of the literature.

METHODS Any studies involving educationalinterventions to improve handover amongstundergraduate or postgraduate doctors or nur-ses were considered. A standardised search ofonline databases was carried out independentlyby both authors and consensus reached on theinclusion of studies. Data extraction and qualityassessment were also completed independently,after which a content analysis of interventionswas conducted and key themes extracted.

RESULTS Ten studies met the inclusion crite-ria. Nine studies reported outcomes demon-

strating improved attitudes or knowledge andskills, and one demonstrated transfer of skills tothe workplace. Amongst the included studies,the strength of conclusions was variable. Poorreporting of interventions impeded replication.Analysis of available content revealed themes inthree major areas: teamwork and leadership;professional responsibility with regard to errorprevention, and information managementsystems. Methods used included exercisesbased on simulation and role-play, and groupdiscussions or lectures focused on errors andpatient safety.

CONCLUSIONS There is a paucity of researchdescribing educational interventions toimprove handover and assessing their effec-tiveness. The quality of published studies isgenerally poor. Some evidence exists to dem-onstrate that skills can be transferred to theworkplace, but none was found to demonstratethat interventions improve patient safety.

medical education in review

Medical Education 2011: 45: 1081–1089doi:10.1111/j.1365-2923.2011.04049.x

1Faculty of Health and Social Care, University of Salford, Salford,UK2Department of Paediatric Gastroenterology, Royal ManchesterChildren’s Hospital, Manchester, UK

Correspondence: Morris Gordon, Room MS 1.90, Mary SeacoleBuilding, University of Salford, Salford, Greater Manchester,M5 4WT, UK. Tel: 00 44 7816 687791; E-mail: [email protected]

ª Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011; 45: 1081–1089 1081

INTRODUCTION

Handover or hand-off is the accurate, reliable com-munication of task-relevant information across shiftchanges1 and is vital to facilitate high-quality healthcare.2 Its importance has increased in recent yearsin the UK as the introduction of the EuropeanWorking Time Directive has resulted in a greaterfrequency of handover as a consequence ofreductions in working hours.3 In the USA, whereworking hours are being similarly reduced,communication failure at handover has been identi-fied as a major source of error within patient care.4

Previous literature has identified failings in currenthandover strategies5–8 and the potential for these toharm patients.9 Numerous published works discussways to improve handover and many of them focus onsystems to manage information, such as standardisedproformas10,11 or electronic handover systems.12,13

There has also been some discussion of the use ofmnemonic devices to guide handover, although thereis a paucity of evidence as to their effectiveness.14

Despite these innovations, research has identifieddissatisfaction amongst junior staff15 with currentpractices as a result of the lack of policies andtraining.16 There have been calls for formal handovereducation17 and work has started to clarify compe-tencies for training.18 In addition, handover isincreasingly recognised within graduate curricula inboth the UK19 and the USA.20

In 2008, Arora et al. presented a theoretical frame-work using theories grounded in social sciences toexplain how handover can impact on patient care.18

They discussed the possible erosion of professionalismoccurring in settings of discontinuity. This can lead tostaff failing to take responsibility for the care ofpatients in a manner that alludes to what is aptlynamed ‘shift-work mentality’, a concept which issupported by agency theory. Under this theory, thepatient does not have access to the information he orshe needs to make an accurate judgement on whethera doctor is behaving in his or her best interest. The‘agency problem’ refers to the potential for doctorsto shirk their professional responsibility in such asetting. This theory would suggest the importanceof professional attitudes to safe handover. Alsodiscussed is the management of information athandover as a source of error and how this relates toan economic theory, known as ‘coordination costs’.This describes how, in increasingly complex systems,the costs (either financial or time-related) ofcoordination, including information management

and communication, increase. Systems are thereforeneeded to safely manage these potential increases.

A complete model of handover practice has previ-ously been reported.21 It describes three overlappingareas of handover practice: (i) information transferand systems for managing information; (ii) responsi-bility and accountability, and (iii) system elements inplace to facilitate handover, such as teamwork andleadership. Recently, theories from the psychologicalsciences have been applied to handover communi-cation.22 This research found that doctors often didnot communicate vital information; they knew whatthey were trying to convey and therefore felt it wasclear to everyone. This overestimation of how wellthey communicated made doctors less likely to verifywhether the receiving doctor had understood. Thisconcept of an egocentric heuristic, associated withhandover communication, led the authors to stressthe importance of focusing on communication withinthe team.22

It is recognised that most junior doctors receive littleor no education in handover6 and this contributesto weaknesses within handover systems.23 The extentto which educational interventions are used toimprove handover and how well the conceptualframeworks and models described here are reflectedin these interventions remain unclear. Evidence forthe effectiveness of these interventions is also unclear.We set out to determine the characteristics ofeducational interventions employed to enhancehandover amongst health professionals and toestablish the effectiveness of these interventions.

METHODS

Data collection

All interventional study designs were considered forthis review. Commentary pieces, surveys, audits orreview articles were not included. The targetpopulation consisted of medical and nursing staff,including undergraduates. The setting was in-patientmedical establishments. Studies involving alliedhealth professionals, who do not hand over within theacute in-patient setting, were excluded. Outcomes atany level of Kirkpatrick’s adapted hierarchy24 wereconsidered for inclusion. Kirkpatrick’s modeldescribes four levels of outcome that can be assessedwhen studying an educational intervention. It istherefore useful to communicate the type of evidencegenerated when investigating an intervention. Level 1

1082 ª Blackwell Publishing Ltd 2011. MEDICAL EDUCATION 2011; 45: 1081–1089

M Gordon & R Findley

describes outcomes associated with the reaction to anintervention, such as satisfaction. Level 2a describesattitudes and confidence, and Level 2b describesknowledge and skills. Level 3 describes outcomesassociated with changed behaviour, such as thetransferring of skills to the workplace. Level 4describes patient outcomes; thus, in the context ofhandover, this may include patient safety data.

An educational intervention was defined as anystructured educational activity. Interventions thatintroduced new handover systems or mnemonicswithout an educational component were excluded.All interventions as defined above were reported. If astudy reported an intervention in limited detail orcommented on improved handover without present-ing evidence in support of the improvement, weattempted to contact the author for further details.Studies from all countries published in all languageswere included. There was no time limit on the search,which was run in June 2010.

The following online databases were searched using astandardised search strategy (Appendix S1, online):MEDLINE; EMBASE; CINAHL (Cumulative Index toNursing and Allied Health Literature); British Nurs-ing Index (BNI); PsycINFO; ERIC (EducationalResource Information Centre); British EducationIndex (BEI), and the Cochrane Trials Database.Additionally, reference lists from included studieswere searched for further relevant studies. Abstractsavailable online from relevant education societies,including the Association for the Study of MedicalEducation (ASME) and the Association for MedicalEducation in Europe (AMEE), were also searched.

Data analysis

Citations were reviewed independently by each of theauthors. Agreement between reviewers was assessedusing Cohen’s kappa statistic. Potentially relevantabstracts were independently reviewed using ascreening checklist (Appendix S2) and full papersobtained for any studies that appeared to meet theinclusion criteria. Disputes were resolved by consen-sus. The full manuscripts for all included studies wereassessed independently by each of the authors. Thequality of the studies was assessed using a dataextraction form (Appendix S3), based on guidanceavailable from Best Evidence Medical Education(BEME),25 as well as the recommendations of Reedet al.26 This rated studies according to each of 16quality-based criteria. The strength of the conclusionsdrawn by each study was rated on a numeric scale,also in line with BEME guidance.25 This is not an

assessment of overall methodological quality, but ameasure of how well the conclusions made aresupported by the data presented. The importance ofoutcomes was also assessed by relating them toKirkpatrick’s adapted hierarchy.24 Disputes in thesejudgements were resolved by discussion between theauthors until they achieved consensus. Contentanalysis of available or supplied interventions, codingand categorisation into themes were carried outindependently by each of the authors.

RESULTS

The initial search of electronic databases identified780 citations, of which 298 were unique. All abstractswere read by both reviewers. Agreement betweenreviewers on citation screening was almost perfect(j = 0.97) and the authors agreed that 40 citationswere potentially relevant. Their abstracts werereviewed using the screening checklist (Appendix S2).There were no potentially relevant abstracts fromscientific meetings of ASME or AMEE. The initialscreening identified a total of 19 studies for fullscreening.

These 19 studies were independently reviewed byeach author and nine papers27–35 were excluded asnot relevant, with no disagreement between theauthors. This left 10 studies36–45 which met theinclusion criteria. No further potentially relevantstudies were found from searching the referenceswithin the included studies. A flow diagram of thesearch is shown in Fig. 1. An overview of the includedpapers is shown in Table 1. Data were extractedindependently by each of the authors, who achievedconcordance on 88% of quality ratings and subse-quently met to reach consensus. Consensus results ofthe quality assessment in each of 16 criteria are shownin Table S1.

There was significant methodological heterogeneityamong the studies, as well as among the educationalinterventions used. Study participants includedmedical students, doctors, nurses and nurse special-ists. The mean number of participants in a studywas 38 (range: 14–72). The studies included sixbefore-and-after studies, three action-based studiesand one non-randomised controlled study. Themajority of studies did not offer details of theintervention used or the resources the interventionrequired. All studies, apart from one,40 had outcomesat Level 2 of Kirkpatrick’s adapted hierarchy,24

measuring either the modification of attitudesor perceptions (Level 2a) or, alternatively, the


Educational interventions to improve handover in health care

modification of knowledge or skills (Level 2b). Theremaining study, by Gakhar and Spencer,40 measuredthe transfer of handover skills into the workplace(Level 3). The strength of conclusions as estimatedusing the BEME scale25 was deemed to be poor in threeof the studies,42–44 which achieved BEME scores of 2.0,representing ambiguous results that may suggest atrend. Three studies36,38,45 achieved BEME scores of3 out of 5, indicating that their conclusions were mostlikely based on results. The strength of conclusionswas judged to be good in four of the studies,37,39–41

which won scores of 4.0, suggesting their conclusionswere clear and very likely to be accurate.

The authors of all but two studies39,40 were contactedand asked to give more information about the inter-ventions used. Five of the authors responded37,38,42–44

by providing narratives of their teaching methods orcopies of materials used that had not been included inthe published manuscripts. These were used in theanalysis of teaching methods and content themes. Thekey outcomes of the analysis are shown in Fig. 2. Themain teaching methods employed were simulation orrole-play, either exclusively, or as part of an overallpackage of measures. Common features were the useof observation, evaluation and feedback. Group lec-tures and online materials were also used in several ofthe interventions.

In line with the literature on the topic, the theme ofinformation management became apparent withinthe content of the educational interventions and was

made clear by the discussion of mnemonics, check-lists or technology. The second theme to emergeconcerned the recognition of error caused by inad-equate handover. This was usually discussed in thecontext of fostering a joint professional responsibilityto prevent such errors, thereby enhancing patientsafety. The third theme concerned team-working andcommunication. A number of ideas were discussedwithin the interventions, such as how to communicateacross a power gradient. Many interventionsinvolved senior members of staff in the training, bothin order to provide models of good practice andto allow these staff to receive handover training.

DISCUSSION

This review found a general paucity of researchsupporting and directing the use of educationalinterventions to improve handover. This is inagreement with the findings of previous research.46

Interestingly, of the 10 studies included, eight hadbeen published in the previous 2 years. This highlightsthe fact that recognition of the need for goodhandover is gaining momentum amongst cliniciansand educationalists, probably in response to worldwidemoves towards decreasing doctors’ working hours. Itis hoped that this systematic review will serve tostimulate further research into the effectivenessof educational interventions to improve handover.

The studies in this review were generally judged to be ofpoor methodological quality (Table S1). Most studiesgave limited information on the specifics of theintervention. Although a number of authors providedfurther details on request, the lack of publishedmaterials limits the scope for other researchers to buildon the educational interventions presented andreaders would struggle to replicate many of them. Anumber of the studies were also considered to haveproposed conclusions that were not supported by thedata they presented. Several factors contributed tothis, including the aforementioned methodologicalweaknesses, the use of multiple system changes thatconfused the impact of the educational component,and the lack of any clear conclusions.

Most studies reported outcomes at Level 2 ofKirkpatrick’s hierarchy; just one study reported out-comes at Level 3, signifying the transfer of skills to theworkplace.40 No study demonstrated that handovereducation could improve patient outcomes (Level 4).Research investigating other methods to improvehandover has also failed to show this.47 As theultimate goal in improving handover is to enhance

Figure 1 Flow diagram of electronic database search



Table 1 Characteristics of included studies

Author(s) YearStudytype Participants Intervention

Outcomemeasures Results Conclusions

Importanceof outcomes

Strength ofconclusion

Berkenstadtet al.36

2008 Before-and-afterstudy

25 nurses Incorporation ofsimulation-basedhandover into afull-day teamworkand communicationworkshop

Improvement inpreconfiguredquality checklistscores of observedhandover

Statistically significantincrease in handover ofinformation after theintervention

Simulation-basedtraining is able toimprove handoverand patient safety

Level 2b 3 ⁄ 5

Chuet al.37


72 interns Seniors give sessionson handover andfeedback to internsreceiving handoverson their firstnight on call

Lectures on handoveronce per month

All part of overallhandover strategy

Survey assessingperceptions ofknowledge,attitudes and abilityto transfer patientcare

Perceptions ofeffectiveness ofhandover process

Statistically significantincrease in perceptionsof ability to hand overpatients, makecontingency plans orperform read backs

The structuredhandoverprogrammeimproved theparticipatinginterns’ perceptionsof their knowledgeof the handoverprocess and theirability to transfercare effectively

The programme waswell received

Level 2a 4 ⁄ 5

Clarket al.38


65 nursesand visitingmedicalofficers

Assertive communicationskills workshop aspart of overall handoverimprovement project

Improvement inconfidence andopinions of staff ona questionnairepost-implementation

80% of staff statedthey were moreconfident athandover post-implementation and68% said handoverhad improved

This early evidencesupports the useof specificcommunicationtraining as itimproves nursingconfidence inhandover

Level 2a 3 ⁄ 5

Farnanet al.39


32 Year4 medicalstudents

90-minute workshop onhandover, electronicaccess to materials onhandover

One week later, a 2-hourstandardised handoverexperience (OSHE)

Creation of handover CEXtool for assessment

Pre- and post-workshop surveys bystudents assessingpreparedness forhandover

Satisfaction of facultystaff with theassessmentinstrument, thehandover CEX

Participant scores forwritten and verbalhandoverperformance

Evaluation of pre- andpost-workshop surveydata revealed astatistically significantimprovement inpreparedness forperforming effectivehandover (27%pre- versus 67% postreporting ‘wellprepared’ or ‘very wellprepared’; p < 0.009)

Students also expressedunanimously positivecomments on theexperience

This brief,standardisedhandover trainingexercise improvedstudents’confidence and wasrated highly bytrained observers

Future work focuseson formal validationof the handover CEXinstrument

Level 2a 4 ⁄ 5

Gakhar &Spencer40


15 doctors(residents)

30-minute lecturefollowed by 30-minutesmall-group practicesession with feedback

Used Yale SIGN-OUTmnemonic45

Pre- and post-trainingobservation of verbalsign-out, completion ofwritten sign-out andconfirmation ofaccuracy of writtenhandout

Statistically significantimprovement inall outcomes, exceptaccuracy of writtenallergy information

The curriculum waswell received byinterns and helpedthem develop skillsrequired by theACGME, includingcompetencies incommunication,practice-basedlearning and systems-based practice

Level 3 4 ⁄ 5

Horwitzet al.41

2007 Action-basedstudy

32 participants:14 interns,14 students,6 other

Curriculum designprocess followed by alarge-group interactivediscussion and thensmall-group sessionsfor 20 minutes withpractice, feedbackand evaluation

Accompanied by anumber of otheronline and printedresources

Use of SIGN-OUTmnemonic

Likert scale ratings forthe course andretrospective pre- andpost- ratings of comfortin giving and receivinghandover

Perceived comfort atproviding sign-outincreased significantly(3.27 ± 1.0 before ver-sus 3.94 ± 0.90 afterwards; p < 0.001)

The oral sign-outcurriculum was wellreceived byparticipants

Further study isnecessary todetermine thelong-term impact ofthe curriculum

Level 2a 4 ⁄ 5

Klamen42 2009 Action-basedstudy

69 medicalstudents

Simulated handoverexperience in smallgroups, as well asvideo and websiteaccompanyingmaterials

Assessment of students’opinions ofintervention and scoreon 10-item handoverchecklist

Mean score of 81.5%on checklist

Positive comments onintervention withmean score of 4.1 ⁄ 5

The simulatedin-patient unit was aneffective and efficientenvironment in whichto teach studentsabout handovers in abusy, demandingin-patient unit setting

Level 2b 2 ⁄ 5



patient safety, this deficiency in evidence must berecognised and future work designed to rectify thesituation.

There are currently no internationally recognisedcompetencies and outcomes for handover education,

which may have contributed to the heterogeneityamongst the educational interventions used in thestudies reviewed here. Despite this, there were anumber of recurring teaching methods. Simulationor role-play were employed by a number of thestudies36,39–42,45 and previous research17 has foundthat doctors feel these are useful in developinghandover skills. These studies employed debriefingand feedback, which have been shown to improveperformance after simulation teaching.48

A number of key content themes were identified; thesecan be related to the previously described theoriesconcerning handover. The first content theme ofinformation management clearly relates to the theoryof ‘coordination costs’18 and refers to the systemsneeded to manage increasingly complex handovers.The second content theme of error relates to thepreviously described agency theory.18 The interven-tions discussed error in the context of fosteringjoint professional responsibility. This challenges the‘shift work’ mentality and therefore may improvepatient safety. The final theme of communicationand team-working relates to the theory of egocentricheuristics,22 which was discussed within a lectureused in one of the interventions.39 These contentareas clearly align with the previously discussedmodel of handover.21 This would seem to be anappropriate model, with a theoretical basis, fordesigning education to enhance handover skills,

Table 1 (Continued)

Author(s) YearStudytype Participants Intervention

Outcomemeasures Results Conclusions

Importanceof outcomes

Strength ofconclusion

Lyonset al.43

2010 Non-randomisedcontrolledstudy

Doctors onneurologycritical careunit (totalnot specified)

Single educationalsession drawing on aliterature review, localaudit and consultants’views

Introduction of ahandover proformaand a change oflocation for handover

Timing and clinicalcontent of handoversevaluated pre- andpost-intervention

A later group ofnon-trained doctorsused as a control group

These factors were cor-related with patients’clinical scores

Significantdifferencein content atbaselineversus post-intervention

Early specific trainingis vital for qualityclinical handover

Level 2b 2 ⁄ 5

Malter &Weinshel44


17 doctors ingastroenterologyresidency training(8 fellows,9 faculty members)

Core lectures onhandover to conveybackgroundinformation on thesubject of handovers,to review focus groupresults, and to educate onthe use of SBAR (situation,background, assessment,recommendation)

Self-assessmentrating of site andpersonal handover

Improvement inmedian selfhandover scoresfor fellows from1–2 to 4

No clear conclusionsDiscussions suggeststhat this programmecould improvecommunication andpatient care

Level 2a 2 ⁄ 5

Nestelet al.45

2005 Action-basedstudy

14 nursespecialists

2-hour teachingintervention onhandoverpresentation skillsusing principles ofadult learning

Interventionevaluated byparticipants interms of learningoutcomes achievedand perceived value

Between 8 and 11participantscompletelyachieved learningoutcomes

All thought thesession was valuable

No clear conclusionsmade

Results presentedsuggest positiveattitudes amongstparticipants towardsthe intervention

Level 2a 3 ⁄ 5

Figure 2 Summary of content themes and teaching meth-ods reported in the included studies



supported by the limited evidence available in theliterature.

The use of these teaching methods and contentthemes is paralleled by work in other fields. TheNational Aeronautics and Space Administration(NASA) determined that many crashes were causedby failures in interpersonal communication, decisionmaking and leadership.49 A teamwork and simula-tion-based intervention to improve safety, designated‘crew resource management’ (CRM) training, wasdeveloped. It focuses on behaviour in teams andencourages the individual to speak up if something isnot being done appropriately. This is intended tocombat the sort of bystander apathy that can occur ingroups, as described in social science theories con-cerning diffusion of responsibility.50 It also embracesthe importance of learning from error to preventrecurrence.51 Training in CRM has already beenadapted in health care, most notably by anaesthe-tists.52 Catchpole et al.53 recently interviewed FormulaOne (F1) racing teams and found similar attitudes tohandover reflecting the same three broad contentthemes. This triangulation with other fields supportsthe utility of the handover model21 for guiding futureeducational design in health care.

This systematic review has several limitations.Although this selection was not limited by languageor date, it included only papers reporting inter-ventions with doctors or nurses in the in-patientsetting. A decision was made to limit the inclusioncriteria in this way as handover itself is not a singlewell-defined task, but is a rather heterogeneousactivity that takes place in many aspects of healthcare and therefore can take many different forms.The screening process excluded a small number ofstudies which reported educational interventionsaimed at improving handover in health care in otherallied groups, such as when patients were movingfrom one primary care establishment to another orarriving by ambulance for care. These describeddifferent models of handover and thus differenttopics for education. A further review looking athandover in all areas of health care may wish toinclude these. This review has followed its remit ofassessing educational interventions to improvehandover, but there are many other forms ofintervention that are also intended to do so. Readersmay wish to research these alternative methods.Most studies gave only limited details of the inter-ventions used and, although some authors offeredextra data, the analysis of content themes andteaching methods is limited by this lack of detail. Itmust also be noted that this review has only included

research of an interventional nature. Although wehave touched upon a number of other streams ofwork in this discussion, we did not undertake athorough review of the wider literature on the topicand this should be considered in any assessmentof our conclusions. All of the studies included inthe review reported positive results of their educa-tional interventions and therefore the possibility ofpublication bias must be considered. Certainly,this lack of negative results inhibits any comments asto the relative impact of different learner character-istics on the success of such interventions. Finally,none of the studies attempted to assess the long-termretention of the outcomes measured and thisfurther limits the conviction with which we canconclude that such interventions are effective.

We would suggest that further work is needed toclarify the competencies required by health care staffto make effective handovers. Such work should take amultidisciplinary view of health care handover andcover the issues of communication across disciplinesand the power gradient. Further assessment andrefinement of the utility of the model for guidinghandover education discussed in this review shouldalso be attempted. We would also suggest that furtherwork is needed to develop interventions to improvehandover skills. The use of methods that parallelCRM and F1 race team training may be considered.Reports of such interventions should give sufficientdetails to allow replication. Whichever investigativetechnique is chosen when assessing such interven-tions should be robustly utilised and well describedon publication. Finally, consideration should be givento the possibility of assessing whether such interven-tions can impact on patient outcomes.

CONCLUSIONS

There is a paucity of research investigating educa-tional interventions to improve handover amongstmedical and nursing staff, although this field isgrowing rapidly. The studies reported suggest thateducational interventions can improve handover,but small sample sizes, the lack of research intolong-term retention and the possibility of publicationbias limit the significance of this conclusion. Themethodological quality of reported studies is generallypoor. There is limited evidence demonstrating thetransfer of skills to the workplace and no evidence thatthese interventions improve patient outcomes.Further work is needed to establish clear competen-cies for handover training. In addition, further



research is required to produce more robust evidenceon the effectiveness of educational handover inter-ventions and their ability to facilitate the transferof skills to the workplace, the ultimate aim of whichis to improve patient safety.

Contributors: MG conceived and designed the project,carried out the literature search, data extraction and analysisand served as lead writer on the manuscript. RF commentedon drafts of the protocol and manuscript and contributedto the literature search, data extraction and analysis. Bothauthors approved the final manuscript for submission.Acknowledgements: the authors thank Dr MadawaChandratilake, Centre for Medical Education, Dundee, forreviewing this manuscript.Funding: none.

Conflicts of interest: none.

Ethical approval: not required.

REFERENCES

1 Lardner R. Effective Shift Handover. London: Health& Safety Executive 1996.

2 Philibert I. Use of strategies from high-reliability orga-nisations to the patient hand-off by resident physicians:practical implications. Qual Saf Health Care2009;18:261–6.

3 Doctors’ training and the European Working TimeDirective. Lancet 2010;375 (9732):2121.

4 Joint Commission on Accreditation of HealthcareOrganizations. Root causes of sentinel events. http://www.jointcommission.org/SentinelEvents/Statistics/.[Accessed 17 August 2010.]

5 Borowitz SM, Waggoner-Fountain LA, Bass EJ, SleddRM. Adequacy of information transferred at residentsign-out (in-hospital handover of care): a prospectivesurvey. Qual Saf Health Care 2008;17:6–10.

6 Horwitz LI, Krumholz HM, Green ML, Huot SJ.Transfers of patient care between house staff oninternal medicine wards. A national survey. Arch InternMed 2006;166:1173–7.

7 Beach C, Croskerry P, Shapiro M. Profiles in patientsafety: emergency care transitions. Acad Emerg Med2003;10:364–7.

8 Gandhi TK. Fumbled hand-offs: one dropped ball afteranother. Ann Intern Med 2005;142:352–8.

9 Arora V, Johnson J, Lovinger D, Humphrey HJ, MeltzerDO. Communication failures in patient sign-out andsuggestions for improvement: a critical incidentanalysis. Qual Saf Health Care 2005;14:401–7.

10 Ferran NA, Metcalfe AJ, O’Doherty D. Standardisedproformas improve patient handover: audit of traumahandover practice. Patient Saf Surg 2008;2:24.

11 Bhabra G, Mackieth S, Montiero P, Pothier D. Anexperimental comparison of handover methods. Ann RColl Surg Engl 2007;89:298–300.

12 Cheah LP, Amott DH, Pollard J, Watters DAK.Electronic medical handover: towards safer medicalcare. Med J Aust 2005;183:369–72.

13 Raptis DA, Fernandes C, Chua W, Boulos PB.Electronic software significantly improves quality ofhandover in a London teaching hospital. HealthInformatics J 2009;15 (3):191–8.

14 Riesenberg L, Leitzsch J, Little B. Systematic review ofhand-off mnemonics literature. Am J Med Qual2009;24:196–204.

15 Kennedy R, Kelly S, Grant S, Cranley B. NorthernIreland general surgery handover study: surgical train-ees’ assessment of current practice. Surgeon 2009;7:10–3.

16 Gordon M. Handover in paediatrics. Junior peceptionsof current practice in the northwest region. Arch DisChild 2010;95 (Suppl 1):69.

17 Cleland JA, Ross S, Miller SC, Patey R. ‘There is achain of Chinese whispers...’: empirical data supportthe call to formally teach handover to prequalificationdoctors. Qual Saf Health Care 2009;18:267–71.

18 Arora VM, Johnson JK, Meltzer DO, Humphrey HJ.A theoretical framework and competency-basedapproach to improving hand-offs. Qual Saf Health Care2008;17:11–4.

19 Royal College of Paediatric and Child Health. Assess-ment standards for Levels 1, 2 and 3. February 2007.http://www.gmc-uk.org/Paediatrics_and_Child_Health_assessment_blueprint.pdf_30586031.pdf.[Accessed 1 June 2010.]

20 Accreditation Council for Graduate Medical Educa-tion. Advancing Education in Interpersonal and Com-munication Skills: an educational resource from theACGME Outcome Project. http://www.acgme.org/outcome/implement/interpercomskills.pdf. [Accessed17 August 2010.]

21 Jeffcott SA, Evans SM, Cameron PA, Chin GSM,Ibrahim JE. Improving measurement in clinicalhandover. Qual Saf Health Care 2009;18:272–7.

22 Chang VY, Arora VM, Lev-Ari S, D’Arcy M, Keysar B.Interns overestimate the effectiveness of their hand-offcommunication. Pediatrics 2010;125:491–6.

23 World Health Organization. Communication duringpatient handovers. Patient Safety Solutions, Vol 1,Solution 3. Geneva: WHO 2007.

24 Barr H, Freeth D, Hammick M, Koppel I, Reeves S.Evaluations of Interprofessional Education: A United King-dom Review of Health and Social Care. London: Centre forthe Advancement of Interprofessional Education(CAIPE), British Educational Research Association2000. http://www.caipe.org.uk/silo/files/evaluations-of-interprofessional-education.pdf. [Accessed 17August 2010.]

25 BEME Collaboration. Best Evidence Medical Education.Dundee: BEME Collaboration 2003. http://www.bemecollaboration.org. [Accessed 17 August 2010.]

26 Reed D, Price EG, Windish DM, Wright SM, Gozu A,Hsu EB, Beach MC, Kern DE, Bass EB. Challenges insystematic reviews of educational intervention studies.Ann Intern Med 2005;142:1080–9.



27 Alem L, Joseph M, Kethers S, Steele C, Wilkinson R.Information environments for supporting consistentregistrar medical handover. HIM J 2008;37 (1):9–25.

28 Pass the baton or NUTS for safer hand-off. J HealthcRisk Manag 2007;29 (10):115–7.

29 Arora V, Johnson J. A model for building a standar-dised hand-off protocol. Jt Comm J Qual Patient Saf2006;32 (11):646–55.

30 Broekhuis M, Veldkamp C. The usefulness andfeasibility of a reflexivity method to improve clinicalhandover. J Eval Clin Pract 2007;13 (1):109–15.

31 Catchpole KR, de Leval MR, McEwan A, Pigott N,Elliott MJ, McQuillan A, MacDonald C, Goldman AJ.Patient handover from surgery to intensive care: usingFormula 1 pit-stop and aviation models to improvesafety and quality. Paediatr Anaesth 2007;17 (5):470–8.

32 Iedema R, Merrick ET, Kerridge R, Herkes R, Lee B,Anscombe M, Rajbhandari D, Lucey M, White L.Handover – Enabling Learning in Communicationfor Safety (HELiCS): a report on achievementsat two hospital sites. Med J Aust 2009;11 (Suppl):133–6.

33 O’Connell B, Penney W. Challenging the handoverritual. Recommendations for research and practice.Collegian 2001;8 (3):14–8.

34 Pesanka DA, Greenhouse PK, Rack LL, Delucia GA,Perret RW, Scholle CC, Johnson MS, Janov CL.Ticket to ride: reducing hand-off risk duringhospital patient transport. J Nurs Care Qual 2009;24(2):109–15.

35 Shendell-Falik N, Feinson M, Mohr BJ. Enhancingpatient safety: improving the patient hand-off processthrough appreciative inquiry. J Nurs Adm 2007;37(2):95–104.

36 Berkenstadt H, Haviv Y, Tuval A, Shemesh Y, Megrill A,Perry A, Rubin O, Ziv A. Improving hand-off commu-nications in critical care: utilising simulation-basedtraining toward process improvement in managingpatient risk. Chest 2008;134 (1):158–62.

37 Chu ES, Reid M, Schulz T, Burden M, Mancini D,Ambardekar AV, Keniston A, Albert RK. A structuredhand-off programme for interns. Acad Med 2009;84(3):347–52.

38 Clark E, Squire S, Heyme A, Mickle ME, Petrie E. ThePACT Project: improving communication at handover.Med J Aust 2009;11 (Suppl):125–7.

39 Farnan JM, Paro JOA, Rodriguez RM, Reddy ST,Horwitz LI, Johnson JK, Arora VM. Hand-off educationand evaluation: piloting the observed simulated hand-off experience (OSHE). J Gen Intern Med 2010;25(2):129–34.

40 Gakhar B, Spencer AL. Using direct observation,formal evaluation, and an interactive curriculum toimprove the sign-out practices of internal medicineinterns. Acad Med 2010;85 (7):1182–8.

41 Horwitz LI, Moin T, Green ML. Development andimplementation of an oral sign-out skills curriculum.J Gen Intern Med 2007;22 (10):1470–4.

42 Klamen D. Students learning in handovers in a simu-lated in-patient unit. Med Educ 2009;43:1081–117.

43 Lyons MN, Standley TDA, Gupta AK. Quality improve-ment of doctors’ shift-change handover in neuro-critical care. Qual Saf Health Care 2010;19 (6):e62.

44 Malter L, Weinshel E. Improving hand-off communi-cation: a gastroenterology fellowship performanceimprovement project. Am J Gastroenterol 2010;105:490–2.

45 Nestel D, Kneebone R, Barnet A. Teaching communi-cation skills for handover: perioperative specialistpractitioners. Med Educ 2005;39 (11):1157.

46 Reisenberg LA, Jaeger J, Padmore JS. Residents’ andattending physicians’ hand-offs: a systematic review ofthe literature. Acad Med 2009;84:1775–87.

47 Cohen MD, Hilligoss PB. The published literature onhand-offs in hospitals: deficiencies identified in anextensive review. Qual Saf Health Care 2010;19 (6):493–7.

48 Hunt E, Shilkofski N, Stavroudis T, Nelson L.Simulation: translation to improved team performance.Anesthesiol Clin 2007;25:301–19.

49 Lerner S, Magrane D, Friedman E. Teaching teamwork inmedical education. Mt Sinai J Med 2009;76:318–29.

50 Darley JM, Latane B. Bystander intervention in emer-gencies: diffusion of responsibility. J Pers Soc Psychol1968;8:377–83.

51 Agency for Healthcare Research and Quality. MedicalTeamwork and Patient Safety. Team training in high-risk contexts. http://www.ahrq.gov/qual/medteam/medteam3.htm. [Accessed 18 August 2010.]

52 Sundar E, Sundar S, Pawloski J. Crew resourcemanagement and team training. Anesthesiol Clin2007;25:283–300.

53 Catchpole K, Sellers R, Goldman A, McCulloch P,Hignett S. Patient handovers within the hospital:translating knowledge from motor racing to health-care. Qual Saf Health Care 2009;19 (4):318–22.

SUPPORTING INFORMATION

Additional Supporting Information may be found in theonline version of this article. Available at: http:/onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2011.04049.x/suppinfo

Table S1. Quality assessment of included studies (consensusratings).

Appendix S1. Search strategy.

Appendix S2. Abstract screening checklist.

Appendix S3. Data extraction form.

Please note: Wiley-Blackwell are not responsible for thecontent or functionality of any supporting materialssupplied by the authors. Any queries (other than formissing material) should be directed to the correspondingauthor for the article.

Received 23 August 2010; editorial comments to authors 21December 2010, 15 March 2011; accepted for publication 4 May2011



Documents

Educational interventions to improve handover in health care: a systematic review