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Review
. 2025 Sep 18;34(10):680-690.
doi: 10.1136/bmjqs-2024-018385.

Use of structured handoff protocols for within-hospital unit transitions: a systematic review from Making Healthcare Safer IV

Sean McCarthy  1 , Aneesa Motala  2   3 , Emily Lawson  2 , Paul G Shekelle  4   2
Affiliations
Review

Use of structured handoff protocols for within-hospital unit transitions: a systematic review from Making Healthcare Safer IV

Sean McCarthy et al. BMJ Qual Saf. .

Abstract

Background: Handoffs are a weak link in the chain of clinical care of inpatients. Within-unit handoffs are increasing in frequency due to changes in duty hours. There are strong rationales for standardising the reporting of critical information between providers, and such practices have been adopted by other industries.

Objectives: As part of Making Healthcare Safer IV we reviewed the evidence from the last 10 years that the use of structured handoff protocols influences patient safety outcomes within acute care hospital units.

Methods: We searched four databases for systematic reviews and original research studies of any design that assessed structured handoff protocols and reported patient safety outcomes. Screening and eligibility were done in duplicate, while data extraction was done by one reviewer and checked by a second reviewer. The synthesis of results is narrative. Certainty of evidence was based on the Grading of Recommendations Assessment, Development and Evaluation framework as modified for Making Healthcare Safer IV.

Results: We searched for evidence on 12 handoff tools. Two systematic reviews of Situation, Background, Assessment, Recommendation (SBAR) (including 11 and 28 original research studies; 5 and 15 were about the use in handoffs) and two newer original research studies provided low certainty evidence that the SBAR tool improves patient safety outcomes. Ten original research studies (about nine implementations) provided moderate certainty evidence that the I-PASS tool (Illness severity, Patient summary, Action list, Situation awareness, Synthesis to receiver) reduces medical errors and adverse events. No other structured handoff tool was assessed in more than one study or one setting.

Conclusion: The SBAR and I-PASS structured tools for within-unit handoffs probably improve patient safety, with I-PASS having a stronger certainty of evidence. Other published tools lack sufficient evidence to draw conclusions.

Prospero registration number: CRD42024576324.

Keywords: Hand-off; Patient Safety; Quality improvement.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1.
Figure 1.
Literature Flow
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References

    1. Agency for Healthcare Research and Quality. Tool: Handoff. Secondary Tool: Handoff May 2023. https://www.ahrq.gov/teamstepps-program/curriculum/communication/tools/h....
    1. Robertson ER, Morgan L, Bird S, Catchpole K, McCulloch P. Interventions employed to improve intrahospital handover: a systematic review. BMJ Qual Saf 2014;23(7):600–7 doi: 10.1136/bmjqs-2013-002309[published Online First: Epub Date]|. - DOI - PubMed
    1. The Joint Commission. Inadequate hand-off communication. Sentinel Event Alert 2017;58(58):1–6 - PubMed
    1. British Medical Association. Safe handover: safe patients. Guidance on clinical handover for clinicians and managers, 2020.
    1. American Medical Association. Safe Handover: Safe Patients. Guidance on Clinical Handover for Clinicians and Managers, 2006.

MeSH terms