Background
The goal of this study was to assess systems and processes involved in the operating
room (OR) to intensive care unit (ICU) handoff in an attempt to understand the criticality
of specific steps of the handoff.
Methods
We performed a failure modes, effects, and criticality analysis (FMECA) of the OR
to ICU handoff of deceased donor liver transplant recipients using in-person observations
and descriptions of the handoff process from a multidisciplinary group of clinicians.
For each step in the process, failures were identified along with frequency of occurrence,
causes, potential effects and safeguards. A Risk Priority Number (RPN) was calculated
for each failure (frequency × potential effect × safeguard; range 1-least risk to
1,000-most risk).
Results
Using FMECA, we identified 37 individual steps in the OR to ICU handoff process. In
total, 81 process failures were identified, 22 of which were determined to be critical
and 36 of which relied on weak safeguards such as informal human verification. Process
failures with the greatest risk of harm were lack of preliminary OR to ICU communication
(RPN 504), team member absence during handoff communication (RPN 480), and transport
equipment malfunction (Risk Priority Number 448).
Conclusion
Based on the analysis, recommendations were made to reduce potential for patient harm
during OR to ICU handoffs. These included automated transfer of OR data to ICU clinicians,
enhanced ICU team member notification processes and revision of the postoperative
order sets. The FMECA revealed steps in the OR to ICU handoff that are high risk for
patient harm and are currently being targeted for process improvement.
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Article info
Publication history
Published online: June 08, 2015
Accepted:
March 25,
2015
Footnotes
This work is funded by AHRQ and NIDDK T32 Training Grants (McElroy 5T32HS78-15, T32DK77662-7) and the NIDDK (1R01DK090129).
Identification
Copyright
© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
