Nara Regina Spall Martins, Edson Zangiacomi Martinez, Cláudia Marquez Simões, Paul Barach, Maria José Carvalho Carmona
{"title":"Analyzing and Mitigating the Risks of Patient Harm During Operating Room to Intensive Care Unit Patient Handoffs.","authors":"Nara Regina Spall Martins, Edson Zangiacomi Martinez, Cláudia Marquez Simões, Paul Barach, Maria José Carvalho Carmona","doi":"10.1093/intqhc/mzae114","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>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 to the intensive care unit are known high-risk events. We describe a novel perspective on how risk factors associated with the process of patient handoff communication between the operating room (OR) and the intensive care unit (ICU) can lead to flawed communication, degraded team awareness, medical errors and increased patient harm.</p><p><strong>Methods: </strong>Data was 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, effects and 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.</p><p><strong>Results: </strong>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 siloes, 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, hospital and staff and are currently targeted for process improvement. Evidence driven recommendations intended for reducing the risks associated with patient handoffs are presented.</p><p><strong>Conclusions: </strong>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.</p>","PeriodicalId":13800,"journal":{"name":"International Journal for Quality in Health Care","volume":" ","pages":""},"PeriodicalIF":2.7000,"publicationDate":"2024-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"International Journal for Quality in Health Care","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1093/intqhc/mzae114","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"HEALTH CARE SCIENCES & SERVICES","Score":null,"Total":0}
引用次数: 0
Abstract
Background: 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 to the intensive care unit are known high-risk events. We describe a novel perspective on how risk factors associated with the process of patient handoff communication between the operating room (OR) and the intensive care unit (ICU) can lead to flawed communication, degraded team awareness, medical errors and increased patient harm.
Methods: Data was 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, effects and 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.
Results: 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 siloes, 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, hospital and staff and are currently targeted for process improvement. Evidence driven recommendations intended for reducing the risks associated with patient handoffs are presented.
Conclusions: 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.
期刊介绍:
The International Journal for Quality in Health Care makes activities and research related to quality and safety in health care available to a worldwide readership. The Journal publishes papers in all disciplines related to the quality and safety of health care, including health services research, health care evaluation, technology assessment, health economics, utilization review, cost containment, and nursing care research, as well as clinical research related to quality of care.
This peer-reviewed journal is truly interdisciplinary and includes contributions from representatives of all health professions such as doctors, nurses, quality assurance professionals, managers, politicians, social workers, and therapists, as well as researchers from health-related backgrounds.