A systematic review of failures in handoff communication during intrahospital transfers

Jt Comm J Qual Patient Saf. 2011 Jun;37(6):274-84. doi: 10.1016/s1553-7250(11)37035-3.


Background: Handoffs serve a critical function in ensuring patient care continuity during transitions of care. Studies to date have predominantly focused on intershift handoffs, with relatively little attention given to intrahospital transfers. A systematic literature review was conducted to characterize the nature of handoff failures during intrahospital transfers and to examine factors affecting handoff communication and the effectiveness of current interventions.

Methods: Primary studies investigating handoff communication between care providers during intrahospital transfers were sought in the English-language literature between 1980 and February 2011. Data for study design, population characteristics, sample size, setting, intervention specifics, and relevant outcome measures were extracted.

Data synthesis: Study results were summarized by the impact of communication breakdown during intrahospital transfer of patients, and the current deficiencies in the process. Results of interventions were summarized by their effect on the quality of handoff communication and patient safety.

Findings: The initial search identified 516 individual articles, 24 of which satisfied the inclusion criteria. Some 19 were primary studies on handoff practices and deficiencies, and the remaining 5 were interventional studies. The studies were categorized according to the clinical settings involved in the intrahospital patient transfers.

Conclusions: There is consistent evidence on the perceived impact of communication breakdown on patient safety during intrahospital transfers. Exposure of handoffs at patient transfers presents challenges that are not experienced in intershift handoffs. The distinct needs of the specific clinical settings involved in the intrahospital patient transfer must be considered when deciding on suitable interventions.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Continuity of Patient Care / organization & administration*
  • Continuity of Patient Care / standards
  • Humans
  • Information Dissemination
  • Interdisciplinary Communication*
  • Patient Transfer / organization & administration*
  • Patient Transfer / standards