Presentation
Operating Room to Intensive Care Unit Patient Handoffs and the Risks of Patient Harm
DescriptionINTRODUCTION: Patients continue to suffer preventable harm and uneven quality. Good clinical outcomes depend on the quality of administrative support systems and processes. Operating room to intensive care unit handoffs are well documented high-risk events for critically ill patients.
OBJECTIVE: We describe the risk factors associated with the process of patient handoff communication between the operating room (OR) and the intensive care unit (ICU) and how they lead to flawed communication and to increased risks of poor patient outcomes.
METHODS: We conducted a prospective, mixed method study with direct observational, ethnographic assessments of several upatient handover performance between the operating rooms and ICU of the tertiary Hospital das Clínicas de São Paulo in São Paulo State, Brazil. The research was developed using the action-research methodology. This was supplemented by two semi-structured focus groups using a failure modes, effects and analysis (FMEA) with a sample of multidisciplinary healthcare providers consisting of attending physicians, nurse managers, bedside nurses, and physiotherapists involved in the patient handoff process.
The focus group interviews were conducted with a semi-structured template for @60 minutes, with various types of stakeholders and 6 participants per group. The focus group interviews were led by an experienced moderator who put participants at ease by encouraging participation and keeping the discussion moving and on target. The moderator recorded the discussions using audio recordings in addition to notes of the non-verbal language. At the end of each focus group, the moderator summarized the information and allowed participants to reflect and comment on the accuracy and validity of this summary.
The topics that guided the question development were the following and after successful piloting were codified into an interview tool to include:
1. knowledge and experience with process risk management concepts;
2. experiences with recent handovers;
3. perceptions about handovers in general (experiences, beliefs, norms, assumptions, methods, tools, barriers, and facilitators);
4. perceptions about role taking, tasks, and responsibilities; and
5. thoughts and suggestions for improving patient handovers.
The second focus group took place after program implementation, intending to evaluate whether the method surfaced potential failures for preventive action and realistic challenges of implementating changes.
Clinicians began by describing, in their own words, the steps in the systems and processes of care involved in the handoff, their specific role and specific tasks performed. This description was graphically depicted as a process map. Clinicians were asked to provide further clarification until consensus was reached. Following each session, the process map was updated.
All interviews were conducted in Portuguese, audiotaped, and transcribed verbatim according to a standardized format where all the speakers were included. The professional transcription corpus was analyzed and each answer to a question constitutes a text. The entire corpus was coded and analyzed using IRaMuTeQ qualitative analysis software The results were analyzed through a similarity matrix to evaluate the steps and effectiveness of a risk management approach.
A risk priority number (RPN) was calculated for each failure (Frequency x Potential effect x Safeguard; range 1-least risk to 1000-most risk).
Ethics: The study protocol was approved by the local Ethics Committee. All participants in the project signed the Informed Consent Form and were not exposed to any additional risks by the research.
RESULTS: Prior to beginning the FMCA, members of the research team conducted ethnographic observations of OR to ICU handoffs to initially identify key steps and all relevant clinical personnel (e.g., transplant surgeon, scrub nurse, anesthesiology fellow) involved in the handoff. As a result, a schema of the OR to ICU handoff process was created. Any safeguards against process failure or patient harm observed by the researchers were also noted.
The FMEA was performed by engaging all relevant clinicians with knowledge and experience in the process of interest, identified by the ethnographic observations. The FMEA identified 38 individual steps in the OR to ICU handoff process, and identified 12 process failures and 36 causes that generated 12 consequences and determined preventive measures to mitigate these risks and which relied on weak safeguards such as informal human verification.
Failures identified during the FMCA were verified with the ethnographic observation notes. The clinical teams reported this approach allowed them to see the process as a whole more fully and not only in their narrow professional roles, understanding the facilities and difficulties of the other team members involved in the care process and how this understanding affects their mental models, subsequent activities and the overall clinical process. We identified detailed risks associated with patients, staff, institution, and potential financial risks.
*Limitations of this study include those inherent to FMEA methodology such as its inherent dependence on the subjective experiences of the individual, clinician participants, in which a failure mode or effect may be missed or exaggerated. Second, his study was conducted at a single institution and there are undoubtedly varying experiences in different institutions. Third, the interviews were transcribed in Portuguese. This may have increased the chance for variations in the interpretation of our data. We made all efforts to ensure the methodological rigor and validity of the translations to English using a standardized codebook, meeting frequently, sharing and comparing our results, and by performing a pilot analysis. Throughout the study, we conducted an ongoing internal quality audit, adapted from Mays and Pope, and from Tong et al, to determine whether the data were collected, analyzed, and reported correctly according to the study protocol.
CONCLUSIONS: The best way to prevent the majority of postoperative complications is to ensure there is a complete and effective hand-off between teams. An effective OR to ICU handoff can potentially enhance prompt detection and mitigation of postoperative complications. 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 tempate sets. Implementing a novel risk management approach allowed healthcare providers to evaluate the process more clearly, making it possible to identify detailed failures, causes, consequences, risks and define action plans to mitigate risks and improve patient safety. The FMEA tool in the toolbox of risk managers, human factors experts and safety leads and is a valuable method for addressing critical issues related to the OR to ICU patient handoffs and are currently being targeted for process improvement in all aspects of handover quality and reliability. We will present detailed recommendations and their implementation results for reducing the risks associated with patient handoffs and are currently being targeted for process improvement.
OBJECTIVE: We describe the risk factors associated with the process of patient handoff communication between the operating room (OR) and the intensive care unit (ICU) and how they lead to flawed communication and to increased risks of poor patient outcomes.
METHODS: We conducted a prospective, mixed method study with direct observational, ethnographic assessments of several upatient handover performance between the operating rooms and ICU of the tertiary Hospital das Clínicas de São Paulo in São Paulo State, Brazil. The research was developed using the action-research methodology. This was supplemented by two semi-structured focus groups using a failure modes, effects and analysis (FMEA) with a sample of multidisciplinary healthcare providers consisting of attending physicians, nurse managers, bedside nurses, and physiotherapists involved in the patient handoff process.
The focus group interviews were conducted with a semi-structured template for @60 minutes, with various types of stakeholders and 6 participants per group. The focus group interviews were led by an experienced moderator who put participants at ease by encouraging participation and keeping the discussion moving and on target. The moderator recorded the discussions using audio recordings in addition to notes of the non-verbal language. At the end of each focus group, the moderator summarized the information and allowed participants to reflect and comment on the accuracy and validity of this summary.
The topics that guided the question development were the following and after successful piloting were codified into an interview tool to include:
1. knowledge and experience with process risk management concepts;
2. experiences with recent handovers;
3. perceptions about handovers in general (experiences, beliefs, norms, assumptions, methods, tools, barriers, and facilitators);
4. perceptions about role taking, tasks, and responsibilities; and
5. thoughts and suggestions for improving patient handovers.
The second focus group took place after program implementation, intending to evaluate whether the method surfaced potential failures for preventive action and realistic challenges of implementating changes.
Clinicians began by describing, in their own words, the steps in the systems and processes of care involved in the handoff, their specific role and specific tasks performed. This description was graphically depicted as a process map. Clinicians were asked to provide further clarification until consensus was reached. Following each session, the process map was updated.
All interviews were conducted in Portuguese, audiotaped, and transcribed verbatim according to a standardized format where all the speakers were included. The professional transcription corpus was analyzed and each answer to a question constitutes a text. The entire corpus was coded and analyzed using IRaMuTeQ qualitative analysis software The results were analyzed through a similarity matrix to evaluate the steps and effectiveness of a risk management approach.
A risk priority number (RPN) was calculated for each failure (Frequency x Potential effect x Safeguard; range 1-least risk to 1000-most risk).
Ethics: The study protocol was approved by the local Ethics Committee. All participants in the project signed the Informed Consent Form and were not exposed to any additional risks by the research.
RESULTS: Prior to beginning the FMCA, members of the research team conducted ethnographic observations of OR to ICU handoffs to initially identify key steps and all relevant clinical personnel (e.g., transplant surgeon, scrub nurse, anesthesiology fellow) involved in the handoff. As a result, a schema of the OR to ICU handoff process was created. Any safeguards against process failure or patient harm observed by the researchers were also noted.
The FMEA was performed by engaging all relevant clinicians with knowledge and experience in the process of interest, identified by the ethnographic observations. The FMEA identified 38 individual steps in the OR to ICU handoff process, and identified 12 process failures and 36 causes that generated 12 consequences and determined preventive measures to mitigate these risks and which relied on weak safeguards such as informal human verification.
Failures identified during the FMCA were verified with the ethnographic observation notes. The clinical teams reported this approach allowed them to see the process as a whole more fully and not only in their narrow professional roles, understanding the facilities and difficulties of the other team members involved in the care process and how this understanding affects their mental models, subsequent activities and the overall clinical process. We identified detailed risks associated with patients, staff, institution, and potential financial risks.
*Limitations of this study include those inherent to FMEA methodology such as its inherent dependence on the subjective experiences of the individual, clinician participants, in which a failure mode or effect may be missed or exaggerated. Second, his study was conducted at a single institution and there are undoubtedly varying experiences in different institutions. Third, the interviews were transcribed in Portuguese. This may have increased the chance for variations in the interpretation of our data. We made all efforts to ensure the methodological rigor and validity of the translations to English using a standardized codebook, meeting frequently, sharing and comparing our results, and by performing a pilot analysis. Throughout the study, we conducted an ongoing internal quality audit, adapted from Mays and Pope, and from Tong et al, to determine whether the data were collected, analyzed, and reported correctly according to the study protocol.
CONCLUSIONS: The best way to prevent the majority of postoperative complications is to ensure there is a complete and effective hand-off between teams. An effective OR to ICU handoff can potentially enhance prompt detection and mitigation of postoperative complications. 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 tempate sets. Implementing a novel risk management approach allowed healthcare providers to evaluate the process more clearly, making it possible to identify detailed failures, causes, consequences, risks and define action plans to mitigate risks and improve patient safety. The FMEA tool in the toolbox of risk managers, human factors experts and safety leads and is a valuable method for addressing critical issues related to the OR to ICU patient handoffs and are currently being targeted for process improvement in all aspects of handover quality and reliability. We will present detailed recommendations and their implementation results for reducing the risks associated with patient handoffs and are currently being targeted for process improvement.
Event Type
Oral Presentations
TimeMonday, March 251:48pm - 2:06pm CDT
LocationSalon A-3
Patient Safety Research and Initiatives