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O C T O B E R 2 0 1 5 | O U T P AT I E N T S U R G E R Y M A G A Z I N E O N L I N E
When mistakes do happen, they start a cascade of unwanted events,
ranging from minor incidents to serious safety events. For example,
the failure to anticipate the need for particular supplies due to an
inadequate handoff may seem like a minor hiccup, but if you look
more closely at the unintended consequences of the mistake, you'll
notice that it can extend anesthesia time, cause cases to last longer
than they should and, subsequently, frustrate surgeons and negatively
impact the surgical team's performance.
We recently faced handoff issues at our hospital. There wasn't a stan-
dard protocol across perioperative services, and recent staff changes
mixed nurses with various experiences, which caused confusion about
communication expectations during patient exchanges. We were per-
forming handoffs, but not very well. We also heard these comments
from the nurses and anesthesia providers involved in handoffs:
• "Don't worry, we have all the info written down in the chart."
• "I don't have time for this."
• "Please hurry, I have other lunch reliefs to do."
If you sense your staff's focus on handoffs is slipping, take a few
minutes to reinforce the importance of clean exchanges. Role-play
proper interactions at your next staff meeting, so staff see and hear
what you expect to occur when patients move from one clinical area
to another. Good handoffs lead to a nearly seamless transition of care
that dramatically improves patient safety. OSM
Ms. Wasserman (margaret.wasserman@advocatehealth.com) is the senior analyst of physician peer
review and a certified ACS NSQIP surgical clinical reviewer at Advocate Illinois Medical Center in Chicago, Ill.
