At a time when patient safety is being linked to reimbursement, handoff of care from one provider/team to another has been identified as a time of vulnerability for the patient. The Joint Commission has stated that communication failure during this critical time may be the cause of up to 30% of sentinel events in the peri-operative period. To promote safety, The Joint Commission has identified patient handover as a top 5 initiative. Closed claims studies have identified a link between handover of care and negative outcomes based on the incomplete transfer of information.
A prospective study by Hudson et al published in the J Cardiothorac Vasc Anesth. (J Cardiothorac Vasc Anesth. 2015 Feb;29(1):11-6. doi: 10.1053/j.jvca.2014.05.018. Epub 2014 Nov 24.) explored the link between patient handover and outcome looking specifically at patients receiving cardiac surgery. They documented that errors/omissions in transferring patient information from one team to the next resulted in harm to the patient. In their study, the authors found that when was transferred from one team to another during cardiac surgery there was a 43% greater risk of in-hospital mortality and a 27% greater risk of morbidity.
Regardless of the type of case, transfer of information from one team to another both in the operating room and in the PACU is essential for patient safety. Intraoperative team changes should be kept to a minimum and anesthesia providers must resist production pressure and give a full and complete report when leaving patients in PACU or ICU.
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