Operating room to intensive care unit handoffs and the risks of patient harm.

Conference Paper

BACKGROUND: The goal of this study was to assess systems and processes involved in the operating room (OR) to intensive care unit (ICU) handoff in an attempt to understand the criticality of specific steps of the handoff. METHODS: We performed a failure modes, effects, and criticality analysis (FMECA) of the OR to ICU handoff of deceased donor liver transplant recipients using in-person observations and descriptions of the handoff process from a multidisciplinary group of clinicians. For each step in the process, failures were identified along with frequency of occurrence, causes, potential effects and safeguards. A Risk Priority Number (RPN) was calculated for each failure (frequency × potential effect × safeguard; range 1-least risk to 1,000-most risk). RESULTS: Using FMECA, we identified 37 individual steps in the OR to ICU handoff process. In total, 81 process failures were identified, 22 of which were determined to be critical and 36 of which relied on weak safeguards such as informal human verification. Process failures with the greatest risk of harm were lack of preliminary OR to ICU communication (RPN 504), team member absence during handoff communication (RPN 480), and transport equipment malfunction (Risk Priority Number 448). CONCLUSION: Based on the analysis, recommendations were made to reduce potential for patient harm during OR to ICU handoffs. These included automated transfer of OR data to ICU clinicians, enhanced ICU team member notification processes and revision of the postoperative order sets. The FMECA revealed steps in the OR to ICU handoff that are high risk for patient harm and are currently being targeted for process improvement.

Full Text

Duke Authors

Cited Authors

  • McElroy, LM; Collins, KM; Koller, FL; Khorzad, R; Abecassis, MM; Holl, JL; Ladner, DP

Published Date

  • September 2015

Published In

Volume / Issue

  • 158 / 3

Start / End Page

  • 588 - 594

PubMed ID

  • 26067459

Pubmed Central ID

  • PMC4536086

Electronic International Standard Serial Number (EISSN)

  • 1532-7361

Digital Object Identifier (DOI)

  • 10.1016/j.surg.2015.03.061

Conference Location

  • United States