Two Minutes to Improve Cardiac Surgery Outcomes
Patient care handoffs are an obligatory component of modern hospital care. A 2006 study of internal medicine practices estimated that 15 physician-to- physician handoffs take place during a hospital stay of 5 days.1 Surgical patients require even more frequent (and complex) handoffs due in part to the requisite handoff between operating room and postoperative care providers. Thus, perioperative leaders emphasize the critical nature of patient handoffs supported by numerous publications in anesthesiology, surgery, and nursing literature. But despite numerous efforts to improve care transfers, errors and omissions continue to occur. A European study evaluating 100 operating room to postanesthesia care unit handoffs found a median of 8 information omissions and 3 task errors per handoff.2 Given the intensity and complexity of patients being admitted to the intensive care unit (ICU) after surgery, it is likely that handoff errors are even more common. For instance, a study evaluating 134 pediatric intensive care unit admissions found a prevalence of 100% in communication errors, with 94% of handoffs containing more than 1 error.