Analysis of risk of patient harm during OR to ICU handoffs

Editor's Note

Based on their analysis of systems and processes involved in OR to intensive care unit (ICU) handoffs, researchers from Northwestern University Feinberg School of Medicine, Chicago, and Washington University School of Medicine, St Louis, made recommendations to reduce potential for patient harm. These included automated transfer of OR data to ICU clinicians, enhanced ICU team member notification processes, and revision of postoperative order sets.

Process failures with the greatest risk of harm were lack of preliminary OR to ICU communication, team member absence during handoff communication, and malfunction of transport equipment.