Making surgical handovers safer

Ms Jessica Ryan and Prof Deborah McNamara discuss an innovative study funded by the Medical Protection Society Foundation, which shows how a simple, four-step surgical handover system can enhance safety for patients

Every morning, surgical teams meet to hand over emergency patients from the night before. This is a high-stakes communication event. Missing information, unclear priorities, and competing clinical demands can turn a routine exchange into a point of vulnerability for patients. This problem has grown as working time limits increased the number of handovers of care without a corresponding increase in training or support. Despite available guidance, many doctors work autonomously. As a result, practice remains highly variable, and safety has depended on individual effort rather than system innovations. We identified a major evidence gap, a lack of a gold standard for practice. Our research group felt there had to be a safer, more standardised approach to handover.

Designing a new approach to handover

To tackle this problem, we undertook a programme of research. We carried out a systematic review of 41 interventional studies highlighting gaps in the literature and best evidence; a systematic review of educational interventions, which informed the design of a new handover training curriculum; a mixed-methods, multisite study to identify common pitfalls and barriers to practice; a national survey of surgical trainees in Ireland to assess practice on a wider scale; and an observational study examining the impact of involving junior team members in the handover process.

A major finding was the persistent misconception that handover involves one-way transmission of information, with most interventions relying on documentation or electronic tools. In reality, handover is a conversation between colleagues that must achieve both accurate information transfer and confirmation of understanding. This body of work led us to design an evidence-based behavioural intervention that addressed all identified gaps in practice and focused on the moments of highest communication risk. Previous successful handover models target only the individual patient presentations. Our intervention restructured the entire meeting from start to finish.

A major finding was the persistent misconception that handover involves one-way transmission of information, with most interventions relying on documentation or electronic tools

The SIPS surgical handover system

This is a four-step system that defines the minimum required for safe surgical handover:

S – Sick patients – Start the handover with a discussion of the highest risk patients;

I – ISBAR – Use succinct, structured patient presentations: Identity, situation, background, assessment, recommendation;

P – Prioritise – Provide a list of the most urgent patients and tasks for the next shift;

S – Summarise – The receiving team closes with a brief recap to confirm shared understanding.

What we studied

Over three years, we implemented SIPS across two university hospitals and compared outcomes before and after the change. In total, the study included 2,261 emergency general surgery patients, 126 handover meetings, and 182 staff members across both sites.

Our evaluation covered:

▶ Handover quality (independent observations by trained research nurses);

▶ Patient physiology (changes in early warning scores at six, 12, and 24 hours);

▶ Safety events (daily staff reports of handover-related issues);

▶ Staff experience (surveys of efficiency, quality and safety);

▶ Implementation (evaluation of adoption, fidelity and sustainability).

What changed with SIPS

1. Better handover, same meeting length. After SIPS, handover meetings were significantly better quality without lasting longer. The sickest patients were flagged at the outset in almost every meeting (98.6 per cent vs 4 per cent), priorities were documented far more often (79.6 per cent vs 28 per cent), and the receiving team closed with a summary in the majority of handovers (86.7 per cent vs 4 per cent, all p<0.001).

2. Clear improvements in patient physiology. A higher proportion of patients had improved vital signs within 12 hours (21.5 per cent vs 16.8 per cent), with an even greater effect by 24 hours (26.8 per cent vs 20 per cent, both p<0.01) when SIPS handover is used. This demonstrates that structured communication translates into measurable direct patient benefit.

3. Fewer safety issues and better staff experience. Staff reported fewer handover related safety events after SIPS was introduced (5 per cent vs 20 per cent, p=0.004). They also rated handover as more efficient, safer and of higher quality, with fewer instances of missing information and fewer patients who turned out to be sicker than expected (p<0.05 for all).

What SIPS does not do (and why that is okay)

SIPS does not replace electronic lists or specialty-specific proformas. It sits above them as a structured human-to-human conversation. It will not fix insufficient staffing or inadequate infrastructure. But it supports teams to work safely and deliver the best possible care within existing constraints. Nor does it replace clinical judgement; it simply defines the safe minimum for handover. Teams can add more detail as needed.

Limitations and what is next

Our evaluation used a before-and-after design rather than randomisation, and clinical data were collected retrospectively from paper charts. These are real-world limitations familiar to most readers. Even so, we observed credible improvements in patient physiology and safety without lengthening meetings. Our manuscript, recently published in JAMA Network Open, reports the full results of our study.

We are thankful to have had the support of the MPS Foundation – a global not-for-profit research initiative that invests in research into patient safety and the wellbeing of healthcare professionals – to progress this work. Next, we plan to test SIPS at scale in hospitals with digital patient records and real-time data capture and we look forward to sharing these findings.

References available on request

Ms Jessica M Ryan is a surgical researcher at RCSI focused on surgical team communication and patient safety. She led the design and evaluation of SIPS across two Irish hospitals as part of her recently completed PhD.

Prof Deborah McNamara is President of RCSI and Consultant General and Colorectal Surgeon at Beaumont Hospital, Dublin.