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

Publication ,  Conference
McElroy, LM; Collins, KM; Koller, FL; Khorzad, R; Abecassis, MM; Holl, JL; Ladner, DP
Published in: Surgery
September 2015

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.

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Published In

Surgery

DOI

EISSN

1532-7361

Publication Date

September 2015

Volume

158

Issue

3

Start / End Page

588 / 594

Location

United States

Related Subject Headings

  • Surgery
  • Risk Assessment
  • Patient Transfer
  • Patient Harm
  • Patient Handoff
  • Outcome and Process Assessment, Health Care
  • Operating Rooms
  • Liver Transplantation
  • Intensive Care Units
  • Humans
 

Citation

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ICMJE
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McElroy, L. M., Collins, K. M., Koller, F. L., Khorzad, R., Abecassis, M. M., Holl, J. L., & Ladner, D. P. (2015). Operating room to intensive care unit handoffs and the risks of patient harm. In Surgery (Vol. 158, pp. 588–594). United States. https://doi.org/10.1016/j.surg.2015.03.061
McElroy, Lisa M., Kelly M. Collins, Felicitas L. Koller, Rebeca Khorzad, Michael M. Abecassis, Jane L. Holl, and Daniela P. Ladner. “Operating room to intensive care unit handoffs and the risks of patient harm.” In Surgery, 158:588–94, 2015. https://doi.org/10.1016/j.surg.2015.03.061.
McElroy LM, Collins KM, Koller FL, Khorzad R, Abecassis MM, Holl JL, et al. Operating room to intensive care unit handoffs and the risks of patient harm. In: Surgery. 2015. p. 588–94.
McElroy, Lisa M., et al. “Operating room to intensive care unit handoffs and the risks of patient harm.Surgery, vol. 158, no. 3, 2015, pp. 588–94. Pubmed, doi:10.1016/j.surg.2015.03.061.
McElroy LM, Collins KM, Koller FL, Khorzad R, Abecassis MM, Holl JL, Ladner DP. Operating room to intensive care unit handoffs and the risks of patient harm. Surgery. 2015. p. 588–594.
Journal cover image

Published In

Surgery

DOI

EISSN

1532-7361

Publication Date

September 2015

Volume

158

Issue

3

Start / End Page

588 / 594

Location

United States

Related Subject Headings

  • Surgery
  • Risk Assessment
  • Patient Transfer
  • Patient Harm
  • Patient Handoff
  • Outcome and Process Assessment, Health Care
  • Operating Rooms
  • Liver Transplantation
  • Intensive Care Units
  • Humans