An observational study of postoperative handoff standardization failures

Application of Within-Methods Triangulation to Analyze Hospital System Health

“…Millions of injuries and hundreds of thousands of deaths occur yearly in the United States from preventable errors 28,29. Many interventions have been implemented at the bedside; however, significant harm from preventable errors has continued at worrying rates 29-35. Although most interventions have been applied at the point of care, it has been suggested that the impetus of adverse events stems from factors at the system level, rather than isolated instances of human error 36,37.…”

“…28,29 Many interventions have been implemented at the bedside; however, significant harm from preventable errors has continued at worrying rates. [29][30][31][32][33][34][35] Although most interventions have been applied at the point of care, it has been suggested that the impetus of adverse events stems from factors at the system level, rather than isolated instances of human error. 36,37 Of note, reports indicate that Magnet-designated hospitals have optimized nurse communication, reduced patient injuries, and 14% lower mortality rates compared with non-Magnet-designated facilities.…”

Handoffs and the challenges to implementing teamwork training in the perioperative environment

“…Perioperative handoffs are particularly challenging due to this setting's unique interdependence of interprofessional roles, acuity and complexity of care, handoff frequency, time constraints, and environmental distractions (Etherington et al, 2019;Abraham et al, 2021b;Michael et al, 2021). Previous interventions have improved perioperative handoff quality; however, high-quality studies demonstrating improved patient outcomes are still needed (Lyons and Popejoy, 2014;Abraham et al, 2021c,d;Stenquist et al, 2022).…”

Guideline for Team Communication

“…“It is very important to incorporate clinician perspectives into a standardized hand‐off process, with future studies focusing on if that aspect impacts patient outcomes.” A new recommendation was added that a standardized hand‐off process should be created for patients transferred from the OR to the intensive care unit 1,7 . Components of this hand off should include flexible but standardized information, customized checklists, time for questions, a tool that encourages shared understanding and common goals and care plans, processes that support the entire hand‐off process, tools that work with the electronic health record to autopopulate and update information, and routine training and implementation 1,8 …”

“…1,7 Components of this hand off should include flexible but standardized information, customized checklists, time for questions, a tool that encourages shared understanding and common goals and care plans, processes that support the entire hand-off process, tools that work with the electronic health record to autopopulate and update information, and routine training and implementation. 1,8…”