Can we make postoperative patient handovers safer? A systematic review of the literature

Anesth Analg. 2012 Jul;115(1):102-15. doi: 10.1213/ANE.0b013e318253af4b. Epub 2012 Apr 27.


Postoperative patient handovers are fraught with technical and communication errors and may negatively impact patient safety. We systematically reviewed the literature on handover of care from the operating room to postanesthesia or intensive care units and summarized process and communication recommendations based on these findings. From >500 papers, we identified 31 dealing with postoperative handovers. Twenty-four included recommendations for structuring the handover process or information transfer. Several recommendations were broadly supported, including (1) standardize processes (e.g., through the use of checklists and protocols); (2) complete urgent clinical tasks before the information transfer; (3) allow only patient-specific discussions during verbal handovers; (4) require that all relevant team members be present; and (5) provide training in team skills and communication. Only 4 of the studies developed an intervention and formally assessed its impact on different process measures. All 4 interventions improved metrics of effectiveness, efficiency, and perceived teamwork. Most of the papers were cross-sectional studies that identified barriers to safe, effective postoperative handovers including the incomplete transfer of information and other communication issues, inconsistent or incomplete teams, absent or inefficient execution of clinical tasks, and poor standardization. An association between poor-quality handovers and adverse events was also demonstrated. More innovative research is needed to define optimal patient handovers and to determine the effect of handover quality on patient outcomes.

Publication types

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

MeSH terms

  • Anesthesia Recovery Period
  • Checklist
  • Clinical Protocols
  • Continuity of Patient Care* / organization & administration
  • Continuity of Patient Care* / standards
  • Guideline Adherence
  • Humans
  • Intensive Care Units
  • Interdisciplinary Communication
  • Medical Errors / prevention & control*
  • Operating Rooms
  • Patient Care Team
  • Patient Safety* / standards
  • Patient Transfer* / organization & administration
  • Patient Transfer* / standards
  • Postoperative Care* / standards
  • Practice Guidelines as Topic
  • Practice Patterns, Physicians'
  • Quality Indicators, Health Care