title: Operating room to intensive care unit handoffs and the risks of patient harm.
abstract: 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Center for Healthcare Studies and Center for Education in Health Sciences, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL. Electronic address: lisa.mcelroy@northwestern.edu.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: McElroy
authors.affiliation: Section of Transplantation, Department of Surgery, Washington University School of Medicine, St. Louis, MO.
authors.forename: Kelly M
authors.initials: KM
authors.lastname: Collins
authors.affiliation: Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL.
authors.forename: Felicitas L
authors.initials: FL
authors.lastname: Koller
authors.affiliation: Center for Healthcare Studies and Center for Education in Health Sciences, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL.
authors.forename: Rebeca
authors.initials: R
authors.lastname: Khorzad
authors.affiliation: Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL.
authors.forename: Michael M
authors.initials: MM
authors.lastname: Abecassis
authors.affiliation: Center for Healthcare Studies and Center for Education in Health Sciences, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL.
authors.forename: Jane L
authors.initials: JL
authors.lastname: Holl
authors.affiliation: Center for Healthcare Studies and Center for Education in Health Sciences, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL.
authors.forename: Daniela P
authors.initials: DP
authors.lastname: Ladner
mesh_terms: D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D016031:Liver Transplantation; D009873:Operating Rooms / Q000458:organization & administration*; D010043:Outcome and Process Assessment, Health Care; D062209:Patient Handoff / Q000458:organization & administration*; D064406:Patient Harm / Q000517:prevention & control*; D010360:Patient Transfer / Q000458:organization & administration*; D018570:Risk Assessment