Analyzing and mitigating the risks of patient harm during operating room to intensive care unit patient handoffs

Patients continue to suffer from preventable harm and uneven quality outcomes. Reliable clinical outcomes depend on the quality of robust administrative systems and reliable support processes. Critically ill patient handoffs from the operating room (OR) to the intensive care unit (ICU) are known to be high-risk events. We describe a novel perspective on how risk factors associated with the process of patient handoff communication between the OR and the ICU can lead to flawed communication, degraded team awareness, medical errors, and increased patient harm. Data were collected from two semi-structured focus groups using a five-step risk management approach at a tertiary hospital in São Paulo, Brazil. We conducted a failure modes and effects analysis (FMEA) with multidisciplinary healthcare providers consisting of attending physicians, anesthesiologists, nurses, and physiotherapists involved in patient handoffs. We analyzed the results using a similitude analysis to evaluate the effectiveness of implementing this novel risk management approach. We identified the handoffs risks associated with patients, staff, institution, and potential financial risks. The FMEA identified 12 process failures and 36 causes that generated 12 consequences and pointed to robust needed preventive measures to mitigate handoff risks. The clinical teams reported that this approach allowed them to see the process more completely as a whole not only in their narrow silos, thus understanding the enablers and difficulties of the other team members and how this understanding can shed light on their mental models, actions, and the process reliability. Teams identified key steps in the OR to ICU handoff process that are prone to the highest hazards to patients, the hospital, and staff, and are currently targeted for process improvement. Evidence-driven recommendations intended for reducing the risks associated with patient handoffs are presented. Implementing a dynamic risk management, interdisciplinary approach was used to redesign the OR to ICU patient handoff approach around the patient's and clinician's needs. The risk management program helped healthcare providers identify handoff steps, highlighting risky handoff process failures, making it possible to identify actionable failures, consequences, and define preventative action plans for mitigating the risks to improve the quality and safety of patient handoffs.