L. M. McElroy1,2, R. Khorzad1,2, M. M. Abecassis2, J. L. Holl1,2, D. P. Ladner1,2 1Northwestern University,Center For Healthcare Studies And Center For Education In Health Sciences, Institute For Public Health And Medicine,Chicago, IL, USA 2Northwestern University,Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center,Chicago, IL, USA
Introduction: The Joint Commission has reported that up to 70% of intra-hospital transfers result in patient harm, and communication breakdowns are at the root of over 60% of sentinel events. The postoperative patient handoff has been identified as a significant source of medical error, and handoffs to the intensive care unit (ICU) have unique challenges that result in higher rates of patient harm. The goal of this study was to identify patient safety risks during the operating room (OR) to ICU handoff using failure mode and effects analysis (FMEA), a prospective method of risk assessment adapted from other high risk industries. Although FMEA is being increasingly used in healthcare for risk assessment, it has not previously been applied to the patient handoff.
Methods: We performed an FMEA of the OR to ICU handoff of deceased donor liver transplant recipients at a tertiary academic hospital. Using in-person observations and descriptions of the handoff process from a multidisciplinary group of clinicians (transplant surgeons and fellows, anesthesiologists and residents, surgical intensivists, surgical residents, and OR and ICU nurses), a comprehensive map of the process was created. 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 x Potential effect x Safeguard; range 1-least risk to 1000-most risk).
Results: The FMEA identified 37 individual steps in the OR to ICU handoff process. In total, 81 process failures were identified, 23 of which were determined to be high-risk and 36 of which relied on weak safeguards such as informal human verification. Process failures with the highest risk of harm were lack of preliminary OR to ICU communication (RPN 504), team member absence during handoff communication (RPN 480), transport equipment malfunction (RPN 448), and errors in postoperative electronic order sets (RPN 432).
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 FMEA revealed steps in the OR to ICU handoff that are high risk for patient harm and are currently being targeted for process improvement.