Human centered design approach improves OR-to-ICU handoffs
Editor's Note A human centered design approach to OR-to-ICU patient handoffs led to improvements in the patient handover process in this study. Researchers uncovered technical and communication flaws when receiving postoperative patients at the Durham, North Carolina, Veterans Affairs Medical Center surgical ICU. The handoff process was redesigned to address…
Web-based handoff tool reduces medical-surgical errors
Editor's Note Hospitals can avoid medical-surgical patient handoff errors by using a web-based handoff tool to improve communication among physicians, nurses, and other healthcare providers, this study finds. Of 5,407 patients included in the study, 77 errors were detected before implementation of the handoff tool versus 45 after implementation. Brigham…
Nontechnical skills also matter in surgical patient safety
Editor's Note Technical and nontechnical skills are both important to successfully and safely perform surgical procedures, according to recommendations presented August 5 at the National Surgical Patient Safety Summit in Rosemont, Illinois. Among the recommendations were that the surgeon, anesthesiologist, nurses, and support staff ensure consistent use of surgical safety…
Joint Commission awards first Integrated Care Certification
Editor's Note The Joint Commission on January 25 announced that Parrish Medical Center, Titusville, Florida, is the first hospital to be awarded its Integrated Care Certification. The Joint Commission began offering the certification in July 2015 to recognize hospitals and ambulatory care settings that excel at integrating information-sharing, transitions of…
Clinician perceptions of OR to ICU handoffs
Editor's Note Ambiguous roles and conflicting expectations of team members during OR to intensive care unit (ICU) handoffs can increase risk of patient harm, this study finds. Researchers conducted 38 interviews of clinicians involved in OR to ICU handoffs to characterize the relationship between handoff process failures and patient harm.…
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…
Barriers to handoff communication in ASCs
Editor's Note Patient handoffs in ambulatory surgery centers are commonly interrupted by distractions that put patients at risk, and nearly 50% might be preventable, this study finds. Handoffs with communication distractions were rated lower in overall quality and associated with a greater number of errors (ie, transfer of incorrect information).…
Getting all OR staff to buy into debriefing process boosts efficacy
The main distinction between good and bad debriefings comes down to the level of staff engagement. That’s what the surgical team at the University of Colorado Hospital, Aurora, learned during a project designed to improve the quality of the 30- to 60-second conversations held after surgery. “In a good debriefing,…
Restructuring and revamping workflow help a small hospital make big strides
Working for a small facility after spending many years at a large one can present a host of leadership challenges, but meeting those challenges with process changes and improved efficiencies can be highly satisfying. After serving more than 23 years at the Cedar Crest campus of Lehigh Valley Health Network…
Team participation and planning produce quality handoffs
After a poor handoff from the OR to the postanesthesia care unit (PACU) was identified as the culprit behind a serious adverse event, Nancy Robinson, DNP, MSN, RN, LHRM, CCM, made it her mission to avoid a recurrence. “I’m passionate about safe patient hand-offs,” says Robinson. “I didn’t want this…
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