The Official Journal of the Anesthesia Patient Safety Foundation Oct 2017
By Steven Greenberg, MD, FCCP, FCCM
The substantial number of preventable deaths and other adverse events associated with health care are now widely recognized.1,2 Handoffs (also called handovers), or transfers in care responsibilities of various types, are among the most important contributors to these outcomes that we must strive to improve. Approximately a decade ago, The Joint Commission (TJC) reported that ineffective communication was the most common reason for sentinel events among a variety of medical specialties.3 Subsequently, TJC made handoff communication a national patient safety goal.3 The Accreditation Council for Graduate Medical Education (ACGME) followed suit and made handoff communication education a requirement for all accredited teaching programs in the US.4 The reduction in resident work hours coupled with the increase in the number and variety of alternative providers participating in patient perioperative care prompted TJC, the ACGME, and other governing bodies to urge for a rational approach to handoff practices.5
The APSF’s mission is to continually improve the safety of patients during anesthesia care by enhancing research, education, and promoting programs that stimulate ideas for positive safety change. As one step toward fulfilling that mission, the APSF has provided funding to investigate the optimal manner for providing perioperative transitions of care. In addition, this year’s Stoelting conference, entitled “Perioperative Handoffs, Achieving Consensus on How to Get It Right,” focused on developing a multidisciplinary consensus on critical elements for safe handoff processes (watch for the conference report in an upcoming issue). Throughout this issue of the APSF Newsletter, we highlight some key topics that point the way toward achieving a goal that no patient should be harmed as a result of a transfer of perioperative care. Dr. Jeffrey Cooper, renowned for his work in this field, convened several experts to describe the various types of handoffs, discuss the evidence for the process and elements of an optimal handoff, examine some challenges of implementation, and consider the creation of a multicenter collaborative to improve the education, research, and implementation of perioperative handoffs. We hope all readers will be motivated to reflect on their own handoff processes and behaviors and hope you and your organizations face the challenge of reducing harm from suboptimal handoff practices by getting involved to work for improvement.
Dr. Greenberg is presently Co-Editor of the APSF Newsletter and Vice Chairperson of Education in the Department of Anesthesiology at NorthShore University HealthSystems in Evanston, IL.
- Institute of Medicine Committee on Quality of Health Care in America. To err is human: building a safer health system. Washington, DC: National Academy; 1999.
- James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf2013;9:122–128.
- The Joint Commission. 2009 National Patient Goals http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals. Accessed August 14, 2017.
- DeRienzo CM, Frush K, Barfield ME, et al. Handoffs in the era of duty hours reform: A focused review and strategy to address changes in the Accreditation Council For Graduate Medical Education common program requirements. Acad Med 2012;87:403–410.
- Greenberg, SB. Seamless transitions of care. In Current concepts in adult critical care. Mount Prospect, IL: Society of Critical Care Medicine, 2016:7-14.