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Empty Handoff
PERIOPERATIVE GRAND ROUNDS Empty Handoff The Case: A 29-year-old man with brittle diabetes (ie, frequent, severe changes in blood glucose levels) was admitted to surgery for incision and drainage of a leg infection. The patient had a history of chronic renal failure, hypertension, and stroke after a hypoglycemic event. While on the hospital floor before surgery, the patient’s blood glucose level fell precipitously after he received insulin, and he required glucose several times. Because of the workload, the nurse did not accompany the patient to the OR but instead informed the transportation assistant about the patient’s extreme sensitivity to insulin and asked that the information be passed along. The transporter, who did not have clinical training, did not understand the significance of the patient’s blood glucose difficulties and forgot to mention them to the perioperative nurse or the anesthesiologist when he transferred the patient. The electronic health record did not reflect earlier glucose levels because the bedside glucose-monitoring device was not docked, so the device did not upload its information. The patient spent 90 minutes in surgery, and, in the recovery room, his blood sugar level was found to be 15 mg/dL. Fortunately, the patient recovered after he received IV glucose.
Discussion: The problem in this case was an error in hand-off communication. Communication failures are the most frequent causes of medical error. In one study, 59% of residents reported they had harmed one or more patients
as a result of hand-offerelated errors, with about one in five reporting major harm.1 Errors that do not lead to harm are frequent and often unreported, and most involve some form of information transfer error.2 The hand off of a patient, information, and equipment among many perioperative personnel (eg, anesthesia, surgery, nursing, intensive care) increases the chance of errors. Hand-off errors can remain undetected for significant periods, as illustrated by this case. The SBAR (situation, background, assessment, and recommendation) mnemonic was developed to standardize hand offs.3 Checklists, the use of which standardizes information exchange, are also common tools. However, both approaches are limited, addressing only one aspect of hand offs, whereas other important aspects can remain unaddressed (eg, distractions, equipment, workspace, training, planning, decision making, follow up).4 Also, many aspects of hand offs have little in common from one procedure to another, so they are difficult to standardize. This case illustrates the complexity of surgical hand offs: a high workload led to a hand off to an unqualified transporter, and the situation was further affected by the error in the electronic health record recording. More than 200 articles about hand offs were published in 2010. Health care providers, however, still struggle to ensure safe hand offs. Measurement of hand offs is difficult, and the association between hand offs (continued on page 395)
This content is adapted from AHRQ Web M&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Allan Goldman, MB, and Ken Catchpole, PhD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, San Antonio, TX. (Citation: Goldman A, Catchpole K. Empty Handoff. AHRQ Web M&M [serial online]. http://webmm.ahrq.gov/case.aspx?caseID¼279. Published September 2012. Accessed December 4, 2013. Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
http://dx.doi.org/10.1016/j.aorn.2014.01.003
448 j AORN Journal
March 2014 Vol 99 No 3
Ó AORN, Inc, 2014
PERIOPERATIVE GRAND ROUNDS (continued from page 448) and outcomes is difficult to demonstrate.5 For example, perceptions versus objective assessments of hand offs suggest that even those we think are effective can have information omissions.6 Three key factors that affect quality during a hand off are information transfer, shared understanding, and working atmosphere.7 One observational study in pediatric cardiac surgery,8 which has been replicated in adult surgery,9 modeled information errors, equipment errors, and teamwork. The multifactorial and interacting nature of the variables within the models suggests complexity but predictability; a standardized process is less reliant on teamwork to avoid errors than a nonstandardized one. The idea of a simple hand-off checklist is attractive, and translating lessons from other systems into health care can yield insights. Procedures or checks evolve over time, and high-performing teams communicate less frequently but more effectively. Therefore, one group studied what OR and intensive care unit (ICU) teams could learn from pit-stop crews.8 The group separated the hand off into four phases. 1.
The OR team sends a form to the ICU personnel, informing them when the patient will be arriving and what equipment and settings will be needed.
2.
The OR team transports the patient to the ICU in silence (unless discussing any safety issues is vital), with all team members knowing their roles.
3.
Both teams confer for the hand off of patient information by using a standardized format that is guided by a form, and key information is repeated.
4.
Both referring and receiving agents agree on a patient plan and contingencies if things go wrong.
The group found that the highest degree of safety was achieved when standard practices and high levels of teamwork were combined. Hand-off preparation, equipment transfer, information transfer, and discussion were coupled with training, safety checks, and integrated documentation. This led to significant performance improvements, which were replicated in additional studies.9,10 The performance gains included fewer process errors and information omissions. Given the dynamic nature of most hand-off situations, a multilayered strategy can be used rather than being reliant on the single hand-off process.11 Although many
www.aornjournal.org
practitioners already perform postehand-off checks, this practice is not routine. Continual review and improvement, based on new studies or local events, are necessary for hand-off safety precaution today.
Perioperative Points: n Errors in hand offs are frequent, complex, and
challenging to define and measure. n Transfer information should include patient status, equipment, and technology, and should be exchanged by using checklists and standardized communication. n A plan should be developed by multiprofessional teams. n A reliable system in increasingly busy clinical settings must be maintained. References 1. Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563-570. 2. Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Ann Surg. 2010; 252(2):402-407. 3. Telem DA, Buch KE, Ellis S, Coakley B, Divino CM. Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results. Arch Surg. 2011;146(1):89-93. 4. Petrovic MA, Martinez EA, Aboumatar H. Implementing a perioperative handoff tool to improve postprocedural patient transfers. Jt Comm J Qual Patient Saf. 2012; 38(3):135-142. 5. Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care. 2010;19(6): 493-497. 6. Manser T. Minding the gaps: moving handover research forward. Eur J Anaesthesiol. 2011;28(9):613-615. 7. Manser T, Foster S, Gisin S, Jaeckel D, Ummenhofer W. Assessing the quality of patient handoffs at care transitions. Qual Saf Health Care. 2010;19(6):e44. 8. Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007;17(5):470-478. 9. Nagpal K, Abboudi M, Fischler L, et al. Evaluation of postoperative handover using a tool to assess information transfer and teamwork. Ann Surg. 2011;253(4):831-837. 10. Petrovic MA, Aboumatar H, Baumgartner WA, et al. Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs. J Cardiothorac Vasc Anesth. 2012;26(1):11-16. 11. Thomas MJ, Schultz TJ, Hannaford N, Runciman WB. Failures in transition: learning from incidents relating to clinical handover in acute care. J Healthc Qual. 2013; 35(3):49-56.
AORN Journal j 395
Discussion: The problem in this case was an error in hand-off communication. Communication failures are the most frequent causes of medical error. In one study, 59% of residents reported they had harmed one or more patients
as a result of hand-offerelated errors, with about one in five reporting major harm.1 Errors that do not lead to harm are frequent and often unreported, and most involve some form of information transfer error.2 The hand off of a patient, information, and equipment among many perioperative personnel (eg, anesthesia, surgery, nursing, intensive care) increases the chance of errors. Hand-off errors can remain undetected for significant periods, as illustrated by this case. The SBAR (situation, background, assessment, and recommendation) mnemonic was developed to standardize hand offs.3 Checklists, the use of which standardizes information exchange, are also common tools. However, both approaches are limited, addressing only one aspect of hand offs, whereas other important aspects can remain unaddressed (eg, distractions, equipment, workspace, training, planning, decision making, follow up).4 Also, many aspects of hand offs have little in common from one procedure to another, so they are difficult to standardize. This case illustrates the complexity of surgical hand offs: a high workload led to a hand off to an unqualified transporter, and the situation was further affected by the error in the electronic health record recording. More than 200 articles about hand offs were published in 2010. Health care providers, however, still struggle to ensure safe hand offs. Measurement of hand offs is difficult, and the association between hand offs (continued on page 395)
This content is adapted from AHRQ Web M&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Allan Goldman, MB, and Ken Catchpole, PhD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, San Antonio, TX. (Citation: Goldman A, Catchpole K. Empty Handoff. AHRQ Web M&M [serial online]. http://webmm.ahrq.gov/case.aspx?caseID¼279. Published September 2012. Accessed December 4, 2013. Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
http://dx.doi.org/10.1016/j.aorn.2014.01.003
448 j AORN Journal
March 2014 Vol 99 No 3
Ó AORN, Inc, 2014
PERIOPERATIVE GRAND ROUNDS (continued from page 448) and outcomes is difficult to demonstrate.5 For example, perceptions versus objective assessments of hand offs suggest that even those we think are effective can have information omissions.6 Three key factors that affect quality during a hand off are information transfer, shared understanding, and working atmosphere.7 One observational study in pediatric cardiac surgery,8 which has been replicated in adult surgery,9 modeled information errors, equipment errors, and teamwork. The multifactorial and interacting nature of the variables within the models suggests complexity but predictability; a standardized process is less reliant on teamwork to avoid errors than a nonstandardized one. The idea of a simple hand-off checklist is attractive, and translating lessons from other systems into health care can yield insights. Procedures or checks evolve over time, and high-performing teams communicate less frequently but more effectively. Therefore, one group studied what OR and intensive care unit (ICU) teams could learn from pit-stop crews.8 The group separated the hand off into four phases. 1.
The OR team sends a form to the ICU personnel, informing them when the patient will be arriving and what equipment and settings will be needed.
2.
The OR team transports the patient to the ICU in silence (unless discussing any safety issues is vital), with all team members knowing their roles.
3.
Both teams confer for the hand off of patient information by using a standardized format that is guided by a form, and key information is repeated.
4.
Both referring and receiving agents agree on a patient plan and contingencies if things go wrong.
The group found that the highest degree of safety was achieved when standard practices and high levels of teamwork were combined. Hand-off preparation, equipment transfer, information transfer, and discussion were coupled with training, safety checks, and integrated documentation. This led to significant performance improvements, which were replicated in additional studies.9,10 The performance gains included fewer process errors and information omissions. Given the dynamic nature of most hand-off situations, a multilayered strategy can be used rather than being reliant on the single hand-off process.11 Although many
www.aornjournal.org
practitioners already perform postehand-off checks, this practice is not routine. Continual review and improvement, based on new studies or local events, are necessary for hand-off safety precaution today.
Perioperative Points: n Errors in hand offs are frequent, complex, and
challenging to define and measure. n Transfer information should include patient status, equipment, and technology, and should be exchanged by using checklists and standardized communication. n A plan should be developed by multiprofessional teams. n A reliable system in increasingly busy clinical settings must be maintained. References 1. Kitch BT, Cooper JB, Zapol WM, et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563-570. 2. Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Ann Surg. 2010; 252(2):402-407. 3. Telem DA, Buch KE, Ellis S, Coakley B, Divino CM. Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results. Arch Surg. 2011;146(1):89-93. 4. Petrovic MA, Martinez EA, Aboumatar H. Implementing a perioperative handoff tool to improve postprocedural patient transfers. Jt Comm J Qual Patient Saf. 2012; 38(3):135-142. 5. Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care. 2010;19(6): 493-497. 6. Manser T. Minding the gaps: moving handover research forward. Eur J Anaesthesiol. 2011;28(9):613-615. 7. Manser T, Foster S, Gisin S, Jaeckel D, Ummenhofer W. Assessing the quality of patient handoffs at care transitions. Qual Saf Health Care. 2010;19(6):e44. 8. Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007;17(5):470-478. 9. Nagpal K, Abboudi M, Fischler L, et al. Evaluation of postoperative handover using a tool to assess information transfer and teamwork. Ann Surg. 2011;253(4):831-837. 10. Petrovic MA, Aboumatar H, Baumgartner WA, et al. Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs. J Cardiothorac Vasc Anesth. 2012;26(1):11-16. 11. Thomas MJ, Schultz TJ, Hannaford N, Runciman WB. Failures in transition: learning from incidents relating to clinical handover in acute care. J Healthc Qual. 2013; 35(3):49-56.
AORN Journal j 395