Professional Documents
Culture Documents
There are three very significant hand-offs that occur in Obviously, there are many opportunities to gather and
perioperative services for each patient who undergoes a communicate critical information that can affect and improve
surgical procedure. The first one is from the pre-operative patient care, prevent injuries and medical errors and ensure
patient care area to the holding room staff. The second one is that your patient has the safest and highest-quality surgi-
from the OR team to OR team members. The third one is from cal outcomes.
the OR team to the post-anesthesia care team.
Adverse events during surgery
There are also additional hand-offs that result for data gathered The list of what can go wrong during a surgical experience is
within each unit or area, depending upon information gath- long and intimidating. Foreign bodies, mislabeled pathology
ered during assessment periods. There can be hand-offs from specimens, operative fires, transfusion and medication errors
holding room staff to anesthesia and the assigned circulator and wrong site, wrong procedure, wrong person surgery are
as well as from circulator to circulator when being relieved for just some of the preventable hazards associated with surgery.1
breaks, lunch and at shift change. The last hand-off occurs Adverse events occur more often in surgery than in any other
when the PACU nurse hands off to the post-op caregiver. specialty, and disproportionately greater harm results from
surgical errors.2
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Patient Safety
interruptions from emergencies, add-ons, delays and compli- 1. Interactive communication that allows for the opportunity
cations. Time becomes a barrier to communication.2 Rushing for questioning between the giver and receiver of
the hand-off can lead to small, yet critical mistakes that can patient information.
ultimately harm patients.2 2. Up-to-date information regarding the patientʼs condition,
care, treatment, medications, services and any recent
Example: A patient who has been in an accident and requires or anticipated changes.
surgery also has a severe shoulder sprain. However, the staff 3. A method to verify the received information, including
members who transfer the patient to preoperative holding repeat-back or read-back techniques.
forget to mention this, so no one else – including the OR, 4. An opportunity for the receiver of the hand-off information
anesthesia, PACU or the floor – is aware of the shoulder to review relevant patient historical data, which may include
sprain. Throughout the care, nurses repeatedly manipulate previous care, treatment or services.
the patientʼs arm during repositioning, causing distress to the 5. Interruptions during hand-offs are limited to minimize
patient and worsening the patientʼs injury.2 the possibility that information fails to be conveyed or
is forgotten.
National Patient Safety Goal 2E The goal further states that an organization should implement
According to the Joint Commission, communication issues are a standardized approach to hand-off communication. Is your
the leading factor in root causes of sentinel events.3 For this process standardized?
reason, the National Patient Safety Goal 2E (NPSG.02.05.01)
was added in 2006. This goal reads as follows: “The [organi- Standardizing hand-off communication
zation] implements a standardized approach to hand-off com- Hand-off communication is defined as the “transfer of infor-
munications, including an opportunity to ask and respond to mation (along with authority and responsibility) during transi-
questions.”3 The elements of performance that are measured tions in care across the continuum for the purpose of ensuring
by the Joint Commission in an organizationʼs hand-off the continuity and safety of the patientʼs care.”4 It is the inter-
process include3: active delivery of accurate and current information about a
patient exchanged from one provider/caregiver to another. To
improve the reliability of workflows accomplishing their desired
goals, and to reduce the risk to patient safety, researchers
recommend structured communications and clear agree- Patient “Hand-Off” Tool Kit that includes nine recommenda-
ments about roles and responsibilities in a hand-off.5 tions for standardized hand-off policy development.4
A clear barrier to hand-off communication is the sheer number Popular hand-off communication systems
of individuals involved in the care of surgical patients. In a Here are four widely used hand-off communication systems:
recent study, it was revealed that the typical surgical patient • “I PASS the BATON” (Introduction, Patient, Assessment,
sees an average of 26.6 health professionals during their Situation, Safety Concerns, Background, Actions, Timing,
hospital stay, compared with the mean of 17.8 health profes- Ownership, Next)
sionals seen by medical patients.2 Therefore a standardized • “I-SBAR” (Introduction, Situation, Background, Assessment,
process for hand-off communication becomes critical in peri- Recommendation)
operative services to ensure that communication is thorough • “PACE” (Patient/Problem, Assessment/Actions, Continuing
and complete among all of the perioperative team members. [treatments]/Changes, Evaluation)
• “Five Ps” (Patient, Plan, Purpose, Problem, Precautions,
Choosing a standardized hand-off method and tool Physician [assigned to coordinate])
Healthcare providers have looked at other high-risk, high-
stakes industries such as aviation, aerospace, nuclear power All four systems are effective as long as there is adherence
and the military for new approaches that can be applied to to the following rules4:
healthcare hand-offs.2 Organizations have also used the Six 1. Conduct the hand-off face-to-face.
Sigma methodology framework to try and better understand 2. Be certain that the hand-off is two-way, with both participants
the process for hand-off communication.6 The development taking joint responsibility for ensuring accurate
of a standardized hand-off communications tool is a dynamic communication.
process that allows continued opportunities for improving the 3. Use verbal and written means of communication.
delivery of patient care.4 AORN has developed a Perioperative 4. Give as much time as necessary to ensure accurate
communication.
Recommendation Five
Redesign the hand-off and shift change processes to pro-
tect against unnecessary interruptions, and allocate suffi-
cient time to the process.
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TeamSTEPPS crewʼs attention being diverted from more critical tasks, the
TeamSTEPPS (Team Strategies and Tools to Enhance Per- Federal Aviation Administration enacted regulations to prohibit
formance and Patient Safety) is an evidence-based team- crew members from performing nonessential duties or activities
training curriculum used by the Department of Defense (DoD). (including conversation) while the aircraft is involved in the
It was developed by the Agency for Healthcare Research and phases of flight most commonly associated with error: taxi,
Quality (AHRQ). takeoff and landing.6
The DoD Patient Safety Program extended permission to This healthcare organization interpreted the sterile cockpit
AORN to customize its existing materials with a focus on concept for the clinical setting during the verbal transfer of
perioperative settings. This is what was used in the develop- patient information. Specifically, only patient-specific conver-
ment of AORNʼs tool kit. The TeamSTEPPS program is an op- sation or urgent clinical interruptions were permitted to occur
portunity for the surgical team to diminish the risk of error and during the hand-off process. They measured their perform-
improve patient outcomes by creating a structure to support ance improvement after implementing the system and found
standardized hand-offs and improve communications during they were able to reduce hand-off turnaround time from 15.3
care transistions.4 Within this kit are numerous tools, minutes to 9.6 minutes.
mnemonics and strategies to be used as templates. The
AORN tool kit is available for free and can be downloaded Formula 1 hand-offs
from www.aorn.org. Another healthcare organization has initiated a new hand-off
process modeled after routine pit stops in racing, which typically
One healthcare organization utilizing the TeamSTEPPS take less than 10 seconds. Each crew member has a specific
curriculum developed a team hand-off model. To minimize job that they know very well. The crew is prepared down to
interruptions and distractions during the hand-off process, this the smallest detail. Safety is the number one concern because
organization modified a concept championed by the aviation the consequences of errors can be life-threatening for both
industry – the “sterile cockpit.” In response to the increasing driver and crew. In contrast to pit stops, hand-offs can be
number of commercial airline accidents involving the cockpit chaotic events involving multiple simultaneous conversations.
Continued on Page 23
This organization utilized a human factors expert along with the recipient is prepared to mentally process. Because of this,
members of the medical staff to study the unique maneuvers many organizations have developed structured communica-
of Formula 1 pit crews. They witnessed many behaviors that tion techniques such as checklists and read-back techniques.6
they then applied to patient hand-offs following surgery. Before The use of a checklist serves two purposes. It ensures that
the hand-off, the surgical team notifies the receiving care- critical information necessary for patient care is not over-
givers of any specific equipment that the patient will need so looked and it provides a consistent order in which infor-
that there is no scrambling to get it set up. The equipment can mation is communicated.
be ready and waiting upon arrival.
These tools serve to address those unique issues or critical
When the patient arrives, there is a routine process that is pieces of information related to continuity of patient care
standardized and takes place in the same order every time. between specialty areas.4 The hand-off checklist or docu-
First, all lines and tubes are untangled and reconnected qui- mentation tool will help ensure a standardized method for
etly and efficiently. Then, the team ensures that the patientʼs everyone to use. Although checklists can enhance memory,
condition is stable before the report begins. The final phase is longer lists might not be as effective. A checklistʼs content and
the report, which utilizes a handover checklist and surgeonʼs design must be prudent and strategic to gain its desired results.
summary. This occurs without distraction from transfer activi-
ties or competing conversations because the receiving team When providing the hand-off communication, remember these
is able to give their full attention to the transferring team as important communication techniques to ensure that there is
the report is given. The hand-off is smooth, efficient and – two-way interaction:
most important – safe.2 • Get the personʼs attention
• Make eye contact
Battling lost data in nursing hand-offs • Face the person
In a study done by Pothier, Monteiro et al, the hand-off of 12 • Use the personʼs name
simulated patients was observed over five consecutive hand- • Express concern
off cycles. Three hand-off styles were used and the amount of • Use a standardized communication technique
data loss was recorded for each style. The purely verbal hand- • Use a standardized communication tool/checklist
off style resulted in the loss of all data after three cycles. A • Re-assert as necessary
note-taking style resulted in only 31 percent of data being • Escalate if necessary
transferred correctly after five cycles. When a printed form
was included with the verbal hand-off, data loss was minimal. Transitions in care are prime targets for improved patient
The authors recommend that nursing and medical staff safety efforts. There are several strategies that have been
include a printed data sheet as part of the hand-off process.4 developed in high-reliability organizations that can be applied
to health care and have been successfully implemented with
AORN describes the preoperative brief as a powerful tool to positive results. For a sample hand-off policy and procedure
“bring the entire OR team onto the same page”; remove as well as checklists and other tools from Trinity Medical
incorrect assumptions; clarify the intended plan and contin- Center in Rock Island, IL, please refer to Pages 82-83
gency plans; obtain key information from surgeons, anesthe- and 85-86 in the Forms & Tools section. Trinity has been
sia providers, circulating nurses and surgical technologists or recognized by the Joint Commission as a model for
scrub nurses that enhances patient care safety and quality hand-off communication.
and develop counter-strategies for avoiding common pitfalls,
errors and complications.4
AORN recommends using four different Pre-Operative Intra-Operative Post-Operative Discharge Brief/Home
hand-off briefs, the Pre-Op Brief, Hand- Pre-Op Brief Hand-Off Post-Op Discharge
Off Briefs for Continuity, Post-Op Brief Briefs for Brief Brief
and Discharge Brief. The diagram to the Continuity
right displays the operating room briefs “Bring the OR Nurse-nurse Anesth to To the patient and
from the OR to discharge home. team onto the Anesth-anesth PACU nurse family for home
same page” by Tech-tech to inpatient care or home
Forms and checklists stating the plan provider health nurse with
To facilitate an individualʼs comprehen- clear diagnosis
sion of what is communicated, informa- and post-op plan
tion must be organized in a format that
References
1 Makary M, Sexton J, Freischlag J. et al. Patient safety in surgery. Ann Surg.
2006;243: 628-635.
2 Stokowski L. Perioperative Nurses: Dedicated to Safe Surgical Care. Available at:
http://www.medscape.com/viewarticle/562998. Accessed November 4, 2008.
3 The Joint Commission. National Patient Safety Goals: History Tracking Report 2009-
2008. Available at: http://www.jointcommission.org/PatientSafety/NationalPatientSafe-
tyGoals/09_hap_npsgs.htm. Accessed November 4, 2008.
4 AORN. Perioperative Patient “Hand-Off” Tool Kit. AORN. Available at:
http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/. Accessed No-
vember 4, 2008.
5 Agency for Healthcare Research and Quality. Patient Safety and Quality: An Evi-
dence-Based Handbook for Nurses. AHRQ Publication No. 08-0043. April 2008.
6 Mistry K, Jaggers J, Lodge A et al. Using Six Sigma® Methodology to Improve Hand-
off Communication in High-Risk Patients. Available at: http://www.ahrq.gov/down-
loads/pub/advances2/vol3/advances-mistry_114.pdf. Accessed November 4, 2008
24 The OR Connection