One example of a catastrophic event would be if a patient were to fall from the bed or stretcher during transfer, leading to injury, medical liability, and negative publicity. Another possible mechanism of injury is the accidental dislodgement of tubes, lines, or drains. Although unplanned removal of tubes and catheters can be very prevalent in the hospital setting, the occurrence is thought to be uncommon in the OR, and very little is written about it in the published literature (Surg Laparosc Endosc Percutan Tech 2020;30:164-8; Anesth Analg 2017;125:846-51).
Published checklists and protocols do exist to ensure optimal performance of both the lateral transfer and the supine to prone transfer, both commonplace in the OR (Clinical Procedures for Safer Patient Care. 2015). However, given the task burden of the anesthesiologist during these maneuvers, it is possible to omit important steps in the process. Therefore, a safety tip to prevent harm during patient transfer is to use a standardized, verbal memory tool, such as described below, to ensure the most critical steps are not forgotten.
The anesthesiologist should verbally announce to the team the following confirmatory questions during the countdown to the transfer:
We are moving (turning) on the count of 3.
One: All lines, drains, and tubes are accounted for, secured and free to move with the patient?
Two: Both beds are securely locked?
Three: (commence transfer)
Using this simple but helpful safety tip may help prevent a patient injury during a transfer. It’s possible that a team member may speak up about a chest tube that doesn’t have enough slack. Likewise, it’s possible that the anesthesiologist may recognize an unlocked OR bed. Most importantly, verbalizing safety concerns helps the entire team recognize their importance and contribute to a culture of safety.
∗ ASA Patient Safety Editorial Board Contributors: Jeffrey A. Green, MD, MSHA, FASA; Alexander F. Arriaga, MD, MPH, ScD; Jonathan B. Cohen, MD; Keith J. Ruskin, MD; Senthilkumar Sadhasivam, MD, MPH, MBA, FASA; Scott C. Watkins, MD; Deborah Schwengel, MD, MEHP (Editor-in-Chief)