Automated transfer of operating room (OR) data to intensive care unit (ICU) physicians is one of the steps that can help limit the many failure modes that accompany this potentially risky patient handoff, according to a study in the September 2015 Surgery. The authors performed a failure modes, effects, and criticality analysis of the handoff process based on both in-person observations and interviews with involved clinicians, focusing on liver donor recipients, among whom postoperative complications are common and significant soon after surgery. They identified 37 individual steps in the handoff process with 81 potential failure modes, of which 36 relied on only weak safeguards for prevention. The failure modes with the greatest risk of harm were OR to ICU communication, team member absence during handoff communication, and transport equipment malfunction. To overcome these concerns, the authors identified recommended steps in the OR before transfer (e.g., creating automatic notifications of the handoff 1 hour before, 30 minutes before, and just before leaving the OR) and in the ICU (e.g., creating a print or digital OR summary data sheet for the ICU team), most of which centered on process standardization and automation.
HRC Recommends: The complexity of critical care presents many opportunities for communication breakdowns among caregivers, disciplines, and departments. Patient handoffs make the ICU especially vulnerable because they involve the transfer of information and responsibility for patient care from one individual, service, or unit to another, often at the busiest times of the day. As such, organizations have been implementing solutions to standardize handoffs. One example is the "ticket to ride," which is a literal ticket that travels with the patient and includes an assessment to be conducted before transport, as well as a checklist to be completed by the initial unit, the transporter, and the receiving unit. Risk managers should consider these and other standardized processes when developing policies and procedures for transfer to and from the ICU.
