Putting the sickest patients first: A practical system to make surgical handover safer

Research team 

1. M. Jessica M. RyanPhDMRCSI and Professor Deborah McNamara MD FRCSI, on behalf of the SURGical Improvement Network (SURGIN) 

The problem with surgical handover  

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.¹ Despite available guidance,^2,3 many doctors work autonomously. As a result, practice remains highly variable,^1,4 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.⁵ 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;⁵ a systematic review of educational interventions which informed the design of a new handover training curriculum;⁶ a mixed-methods, multisite study to identify common pitfalls and barriers to practice;⁴ a national survey of surgical trainees in Ireland to assess practice on a wider scale;¹ and an observational study examining the impact of involving junior team members in the handover process._⁷ 

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.⁸ 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.^9,10 Our intervention restructured the entire meeting from start to finish. 

The SIPS surgical handover system¹¹ 

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 6, 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 

• 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% vs. 4%), priorities were documented far more often (79.6% vs 28%), and the receiving team closed with a summary in the majority of handovers (86.7% vs. 4%, all p<0.001).

• Clear improvements in patient physiology 

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

• Fewer safety issues and better staff experience 

Staff reported fewer handover related‑ safety events after SIPS was introduced (5% vs. 20%, 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 doesn’t do (and why that’s ok) 

SIPS doesn’t replace electronic lists or specialty-specific proformas. It sits above them as a structured human-to-human conversation. It won’t 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’s 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. Next, we plan to test SIPS at scale in hospitals with digital patient records and real-time data capture. 

Resources 

Our recently published manuscript in JAMA Network Open, which reports the results of this study, can be accessed via the following link: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2839650

If you would like access to any of the templates used in this study, contact the team at surgicalhandover@rcsi.com.

Acknowledgements 

This work received grant support from the Medical Protection Society Foundation and Bon Secours Hospital, Dublin. 

About the authors 

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 Professor Deborah McNamara is President of RCSI and Consultant General and Colorectal Surgeon at Beaumont Hospital, Dublin. Professor McNamara has a special interest in healthcare improvement and surgical training, having previously held the roles of Programme Director of the National Higher Surgical Training Programme in General Surgery, Clinical Director for Surgery at Beaumont Hospital, and Co-Lead of the HSE / RCSI National Clinical Programme for Surgery (2017-2024). 

References 

1. Ryan JM, Simiceva A, Toale C, Eppich W, Kavanagh DO, McNamara DA. Assessing current handover practices in surgery: A survey of non-consultant hospital doctors in Ireland.The Surgeon2024. 
2. Abdellatif A, Bagian JP, Barajas ER, Cohen M, Cousins D, Denham CR, et al. Communication during patient hand-overs: patient safety solutions, volume 1, solution 3, May 2007.Joint Commission Journal on Quality and Patient Safety2007;33(7):439-442. 
3. Committee NCE. Communication (Clinical Handover) in Acute and Children’s Hospital Services, National Clinical Guideline.
4. Ryan JM, Simiceva A, Eppich W, Kavanagh DO, McNamara DA. End-of-shift surgical handover: mixed-methods, multicentre evaluation and recommendations for improvement.BJS Open2024;8(2):zrae023. 
5. Ryan JM, McHugh F, Simiceva A, Eppich W, Kavanagh DO, McNamara DA. Daily handover in surgery: systematic review and a novel taxonomy of interventions and outcomes.BJS Open2024;8(2):zrae011. 
6. Simiceva A, Ryan JM, Eppich W, Kavanagh DO, McNamara DA, Morris M. Developing an educational blueprint for surgical handover curricula: a critical review of the evidence.Advances in Health Sciences Education2025. 
7. Murnaghan N, Ryan JM, Duggan WP, McNamara DA. Intern involvement in emergency general surgical handover and implications for patient care.The Surgeon2025. 
8. Cohen MD, Hilligoss B, Kajdacsy-Balla Amaral AC. A handoff is not a telegram: an understanding of the patient is co-constructed.Crit Care2012;16(1):303. 
9. Marshall S, Harrison J, Flanagan B. The teaching of a structured tool improves the clarity and content of interprofessional clinical communication.Qual Saf Health Care2009;18(2):137-140. 
10. Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, et al. Changes in medical errors after implementation of a handoff program.New England Journal of Medicine2014;371(19):1803-1812. 
11. Ryan JM, Lynn TM, Kavanagh DO, Sorensen J, Simiceva A, Eppich W, et al. A Surgical Handover System for Patient Physiology and Safety.JAMA network open2025;8(10):e2538896-e2538896.