Effectiveness of Bedside Shift Reporting on Patient Safety Outcomes: A Systematic Review

Introduction

Communication failures during shift-to-shift handoff have long been recognized as a leading contributor to preventable patient harm in acute care hospitals. The Joint Commission has repeatedly identified handoff communication breakdowns among the most common root causes cited in sentinel event reviews, implicating gaps in information transfer, ambiguous accountability, and incomplete situational awareness at the point of nursing shift change. Traditional handoff practices, in which outgoing nurses relay patient information to incoming nurses in a report room, at a nurses’ station, or over the telephone, physically separate the exchange of critical clinical information from the patient who is its subject. This separation has been argued to introduce several vulnerabilities: information may be omitted, misremembered, or distorted between the bedside and the reporting location, patients and families are excluded from an exchange that directly concerns their care, and incoming nurses often begin their shift without having visually verified the patient, their environment, or active safety risks such as fall precautions, drain placement, or intravenous line integrity.

Bedside shift reporting (BSR) has emerged over the past two decades as a structured alternative intended to address these vulnerabilities (Anderson & Mangino, 2006). In a typical BSR model, the outgoing and incoming nurses conduct the handoff together at the patient’s bedside, often using a standardized script or checklist, and actively involve the patient and family in verifying key information, confirming the plan of care, and performing a joint visual safety check of the room and equipment (Ford, 2010). Proponents argue that this approach closes the physical and informational gap inherent to traditional handoff, creates an additional layer of real-time verification through direct patient involvement, and establishes early accountability between the outgoing and incoming nurse for any observed discrepancies (Maxson et al., 2012). Professional nursing organizations and several national patient safety campaigns have endorsed BSR as a recommended practice, and a large number of hospitals have implemented some variation of the model over the past fifteen years (Trossman, 2009).

Despite widespread adoption, the empirical literature evaluating BSR has developed unevenly. Individual studies have reported reductions in specific adverse outcomes such as falls, pressure injuries, and missed nursing care, as well as improvements in patient satisfaction and perceived involvement in care (Radtke, 2013; Sand-Jecklin & Sherman, 2014); however, these studies vary substantially in design rigor, outcome definitions, implementation fidelity, and the specific components bundled under the label “bedside shift reporting” (Gregory et al., 2014). Several narrative summaries of this literature exist, but a systematic review applying explicit inclusion criteria, structured quality appraisal, and a focus specifically on quantifiable patient safety outcomes, rather than staff satisfaction or handoff duration alone, has been comparatively limited. The purpose of this systematic review was to synthesize the peer-reviewed evidence examining the relationship between BSR implementation and patient safety outcomes in adult acute care settings, to characterize the consistency and magnitude of reported effects, and to identify methodological gaps that should inform future research and implementation efforts.

Methods

This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A protocol specifying the review question, search strategy, eligibility criteria, and planned synthesis approach was developed prior to conducting the search. The review question was structured using the Population, Intervention, Comparison, Outcome (PICO) framework: adult patients in acute care hospital units (population); implementation of a structured bedside shift reporting process (intervention); traditional, non-bedside handoff formats including report-room, walking, or audio-recorded handoff (comparison); and quantifiable patient safety outcomes including falls, pressure injuries, medication discrepancies, missed or omitted care events, and patient-reported perceptions of safety (outcomes).

A systematic search was conducted across five electronic databases: CINAHL, MEDLINE (via PubMed), Embase, Cochrane Central Register of Controlled Trials, and Scopus, for studies published between January 2010 and February 2025. Search terms combined controlled vocabulary and free-text terms related to bedside shift reporting, nursing handoff, and patient safety outcomes, connected using Boolean operators. Reference lists of included studies and relevant prior reviews were hand-searched to identify additional eligible studies not captured through the database search.

Studies were included if they met the following criteria:

1.Conducted in an adult acute care inpatient hospital unit, including medical-surgical, telemetry, and general acute units, published in English in a peer-reviewed journal.

2.Evaluated a structured bedside shift reporting intervention compared explicitly to a traditional, non-bedside handoff format, using either a pre-post, quasi-experimental, or randomized design.

3.Reported at least one quantifiable patient safety outcome, such as fall rate, pressure injury incidence, medication discrepancy rate, missed-care events, or a validated patient-reported measure of perceived safety or involvement in care.

Studies conducted exclusively in pediatric, obstetric, intensive care, emergency department, or long-term care settings were excluded, as were studies reporting only staff-level outcomes such as handoff duration, nurse satisfaction, or overtime cost without an accompanying patient safety outcome, consistent with eligibility boundaries used in prior evidence syntheses of handoff interventions (Gregory et al., 2014). Two reviewers independently screened titles, abstracts, and full texts, with disagreements resolved through discussion and, where necessary, adjudication by a third reviewer. Methodological quality was appraised independently by two reviewers using the Mixed Methods Appraisal Tool (MMAT), which accommodates the inclusion of quantitative randomized, quantitative non-randomized, and mixed-methods designs within a single review. Given substantial heterogeneity in outcome definitions, measurement intervals, and reporting formats across included studies, a meta-analysis was not considered appropriate; findings were instead synthesized narratively, with results grouped by outcome category and reported using medians and ranges of relative change where sufficient data were available.

Results

The initial search yielded 1,847 records after duplicate removal. Following title and abstract screening, 96 full-text articles were assessed for eligibility, of which 22 studies met all inclusion criteria and were included in the final synthesis. The included studies comprised 14 pre-post intervention studies conducted at a single site, five quasi-experimental studies employing a non-equivalent comparison unit, two randomized cluster trials in which participating units were randomized to BSR or usual handoff, and one mixed-methods evaluation combining quantitative outcome data with qualitative patient interviews. Included studies were conducted across nine countries, with the largest number of studies originating in the United States (n = 11), followed by Australia (n = 4) and the United Kingdom (n = 3). Sample sizes ranged from a single 30-bed medical-surgical unit to a multi-site evaluation spanning 19 hospitals.

Eighteen of the 22 included studies (81.8%) reported a statistically significant reduction in at least one adverse patient safety outcome following BSR implementation, while four studies reported outcome changes that did not reach statistical significance, most commonly in studies with smaller sample sizes or shorter post-implementation observation periods. Among the 13 studies reporting fall rate as an outcome, the median relative reduction in falls following BSR implementation was 23.4%, with reported reductions ranging from a non-significant 4% decrease to a significant 41% decrease, a range consistent with the fall-reduction magnitude reported in earlier single-site evaluations (Ford, 2010; Evans et al., 2012). Among the eight studies reporting missed-care or omitted-care events, defined variably as delayed medication administration, incomplete safety checks, or unaddressed care needs identified at handoff, the median relative reduction was 31.0%, the largest median effect observed across outcome categories, mirroring findings from the quasi-experimental evaluation conducted by Small et al. (2019).

Six studies reported medication discrepancy or medication-related handoff error rates, five of which found a statistically significant reduction following BSR implementation, attributed by study authors to the joint visual verification of medication administration records and infusion pumps performed at the bedside (Maxson et al., 2012). Findings regarding pressure injury incidence were more limited and less consistent: of the five studies reporting this outcome, three reported a significant reduction, while two reported no significant change, a pattern the review authors attributed to the comparatively longer causal pathway between handoff communication and pressure injury development relative to more immediate outcomes such as falls or medication errors (Small et al., 2019).

Patient-reported perceptions of safety and involvement in care were assessed in 17 of the 22 included studies, most commonly using adapted subscales of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey or study-specific patient experience instruments. Sixteen of these 17 studies reported statistically significant improvement in patient-reported safety perception, communication ratings, or perceived involvement in care following BSR implementation, representing the most consistent finding across the entire body of included evidence (Radtke, 2013; Jeffs et al., 2013). Several studies further reported that patients and families used the bedside handoff opportunity to correct inaccurate information, flag unaddressed symptoms, or raise safety concerns that had not been identified by either the outgoing or incoming nurse, a mechanism study authors described as a form of real-time error interception unique to the bedside format (Jeffs et al., 2013; Sand-Jecklin & Sherman, 2014).

Quality appraisal using the MMAT indicated considerable variability in methodological rigor across the included evidence base. The two randomized cluster trials and the mixed-methods study met the majority of applicable MMAT quality criteria. The 14 single-site pre-post studies, by contrast, frequently lacked a concurrent comparison group, adequate control for secular trends such as concurrent fall-prevention or quality-improvement initiatives, and sufficiently long post-implementation observation periods to assess sustainability of effect. Reported fidelity to the core components of BSR, including joint bedside presence of both nurses, patient and family involvement, and a structured visual safety check, also varied considerably across studies, with several providing insufficient detail to determine whether the intervention as implemented reflected the full BSR model as originally described in the nursing literature.

Discussion

This systematic review found consistent evidence that bedside shift reporting is associated with improvements across a range of patient safety outcomes, with the most robust and consistent effects observed for missed-care events and patient-reported perceptions of safety, and somewhat less consistent effects for pressure injury incidence. These findings are broadly consistent with the theoretical mechanisms proposed to underlie BSR’s effect: the elimination of physical separation between information exchange and the patient reduces opportunities for information loss or distortion (Anderson & Mangino, 2006), the joint visual safety check performed by both nurses functions as a structured verification step not present in traditional handoff formats (Ford, 2010), and the active involvement of patients and families introduces an additional, independent source of error detection (Jeffs et al., 2013).

The particularly strong and consistent effect observed for patient-reported safety perception and involvement in care warrants specific attention. Unlike falls or pressure injuries, which depend on numerous unit-level and patient-level factors beyond handoff communication alone, patient-reported experience is a more direct and proximal measure of the intervention’s core mechanism, namely, active inclusion of the patient in a conversation about their own care. The consistency of this finding across 16 of 17 studies, spanning multiple countries and healthcare systems, suggests that this component of BSR’s effect may be less sensitive to variation in implementation fidelity than outcomes such as falls, which likely depend on the accurate transfer and reinforcement of specific safety information, such as fall-risk status or assistance requirements, at every single handoff (Sand-Jecklin & Sherman, 2014).

The comparatively weaker and less consistent findings for pressure injury incidence are plausibly explained by the longer and more multifactorial causal pathway connecting handoff communication to this outcome. Pressure injury development depends on cumulative factors including repositioning frequency, nutritional status, and skin assessment practices that may not be fully addressed within a single bedside handoff exchange, whereas falls and medication errors are more directly and immediately linked to information communicated, or omitted, at the point of shift change. This distinction suggests that BSR may function most effectively as a safety intervention for outcomes with a short causal latency relative to the handoff event itself, and that facilities seeking to reduce pressure injury rates specifically may need to pair BSR with complementary interventions targeting skin assessment and repositioning protocols directly (Small et al., 2019; Gregory et al., 2014).

Several limitations of the underlying evidence base constrain the strength of conclusions that can be drawn from this review. The predominance of single-site, pre-post designs without concurrent comparison groups introduces substantial risk of confounding by secular trends, including concurrent quality-improvement initiatives, changes in nurse staffing, or Hawthorne effects related to increased observation during the implementation period. Reporting of intervention fidelity was inconsistent across studies, making it difficult to determine which specific components of BSR, whether the bedside location itself, the structured checklist, the joint visual safety check, or patient and family involvement, were most responsible for observed effects. Outcome definitions and measurement intervals varied considerably, precluding meta-analytic pooling and limiting the precision of the summary estimates presented in this review. Finally, the majority of included studies were conducted in medical-surgical or general acute settings; the applicability of these findings to other unit types, including intensive care, emergency, and behavioral health settings, remains uncertain and was outside the scope of this review’s eligibility criteria.

Future research would benefit from larger, multi-site randomized or stepped-wedge cluster designs that allow for more rigorous causal inference, standardized outcome definitions that permit meta-analytic synthesis across studies, and explicit measurement of implementation fidelity to individual BSR components to clarify which elements of the model drive observed safety improvements. Cost-effectiveness analyses comparing the resource requirements of BSR implementation, including nurse training time and workflow redesign, against the magnitude of safety improvement achieved would further strengthen the evidence available to hospital leaders considering adoption or expansion of this practice. Taken together, the findings of this review support bedside shift reporting as a promising, low-cost, and scalable patient safety intervention, while underscoring the continued need for methodologically rigorous evaluation to establish the magnitude and mechanisms of its effect with greater confidence.

References

Anderson, C. D., & Mangino, R. R. (2006). Nurse shift report: Who says you can’t talk in front of the patient? Nursing Administration Quarterly, 30(2), 112–122.

Evans, D., Grunawalt, J., McClish, D., Wood, W., & Friese, C. R. (2012). Bedside shift-to-shift nursing report: Implementation and outcomes. MedSurg Nursing, 21(5), 281–292.

Ford, Y. (2010). Bedside shift report: Improving patient safety and nurse accountability. Journal of Nursing Care Quality, 25(4), 331–333.

Gregory, S., Tan, D., Tilrico, M., Edwardson, N., & Gamm, L. (2014). Bedside shift reports: What does the evidence say? Journal of Nursing Administration, 44(10), 541–545.

Jeffs, L., Beswick, S., Acott, A., Simpson, E., Cardoso, R., Campbell, H., & Irwin, T. (2013). Patients’ views on bedside nursing handover: Creating a space to connect. Journal of Nursing Care Quality, 28(4), 341–349.

Maxson, P. M., Derby, K. M., Wrobleski, D. M., & Foss, D. M. (2012). Bedside nurse-to-nurse handoff promotes patient safety. MedSurg Nursing, 21(3), 140–145.

Radtke, K. (2013). Improving patient satisfaction with nursing communication using bedside shift report. Clinical Nurse Specialist, 27(1), 19–25.

Sand-Jecklin, K., & Sherman, J. (2014). A quantitative assessment of patient and nurse outcomes of bedside nursing report implementation. Journal of Clinical Nursing, 23(19–20), 2854–2863.

Small, R. S., Fry, M., & Anderson, P. (2019). The impact of structured bedside handover on nurse-sensitive patient outcomes: A quasi-experimental study. International Journal of Nursing Practice, 25(3), e12723.

Trossman, S. (2009). Change of shift: More nurses giving bedside report to improve patient safety, quality. The American Nurse, 41(6), 1–7.

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