Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery.

Joseph R Keebler; Isaac Lynch; Fallon Ngo; Eleanor Phelps; Norman Huang; Oren T. Guttman; Richard Preble; Abu Taher Minhajuddin; Natalie Gamez; Alicia Wanat-Hawthorne; Kenni Landgraf; Emma Minnis; Logan M. Gisick; Mandy McBroom; Aditee Ambardekar; DaiWai Olson; Philip E Greilich

Study

Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery.

July 12, 2023

Keebler JR, Lynch I, Ngo F, et al. Jt Comm J Qual Patient Saf. 2023;49(8):373-383.

View more articles from the same authors.

Handoffs are an inevitable part of hospital care; clear communication between providers is required to ensure safe care. This quality improvement project aimed to improve handoffs between the cardiovascular (CV) operating room and CV intensive care unit by developing, implementing, and sustaining a structured handoff bundle. A participatory design was used to ensure that the tool contained only the key elements to support implementation without overburdening users.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety.

November 28, 2018

Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes.

June 1, 2022

Handoffs and teamwork: a framework for care transition communication.

June 29, 2022

Medication safety in the operating room: literature and expert-based recommendations.

February 22, 2017

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Targeted versus universal decolonization to prevent ICU infection.

May 1, 2013

Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care.

March 17, 2021

Taking up the challenge to improve name and role recognition in the operating room.

February 7, 2024

Effect of genetic diagnosis on patients with previously undiagnosed disease.

November 7, 2018

Incidence, duration and risk factors associated with delayed and missed diagnostic opportunities related to tuberculosis: a population-based longitudinal study.

March 24, 2021

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

How to mitigate the effects of cognitive biases during patient safety incident investigations.

September 28, 2022

"Anybody on this list that you're more worried about?" Qualitative analysis exploring the functions of questions during end of shift handoffs.

September 23, 2015

"Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs.

September 16, 2015

Validation of a teamwork perceptions measure to increase patient safety.

August 27, 2014

Building a program of expanded peer support for the entire health care team: no one left behind.

October 13, 2021

The debrief imperative: building teaming competencies and team effectiveness.

November 16, 2022

Meta-analyses of the effects of standardized handoff protocols on patient, provider, and organizational outcomes.

February 22, 2017

Viewing prevention of catheter-associated urinary tract infection as a system: using systems engineering and human factors engineering in a quality improvement project in an academic medical center.

October 12, 2016

Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review.

January 12, 2022

Preventing home medication administration errors.

March 14, 2022

Association of clinical specialty with symptoms of burnout and career choice regret among US resident physicians.

September 26, 2018

Changes in prevalence of health care-associated infections in U.S. hospitals.

November 14, 2018

Artificial intelligence and surgical decision-making.

March 11, 2020

Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis.

December 20, 2023

Diagnostic assessment of deep learning algorithms for detection of lymph node metastases in women with breast cancer.

January 10, 2018

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive care units: a multicentre retrospective observational study.

October 18, 2023

Development of the barriers to error disclosure assessment tool.

September 27, 2017

Engaging the patient and family in the surgical safety process utilizing SafeStart.

August 28, 2019

Families as partners in hospital error and adverse event surveillance.

March 8, 2017

Validation of a diagnostic reminder system in emergency medicine: a multi-centre study.

October 17, 2007

Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors.

April 3, 2019

A new professionalism? Surgical residents, duty hours restrictions, and shift transitions.

November 17, 2010

Crowding in the Emergency Department: Challenges for the Care of Children.

March 15, 2023

Changes in medical errors after implementation of a handoff program.

November 12, 2014

Association of changing hospital readmission rates with mortality rates after hospital discharge.

August 9, 2017

Learning from lawsuits: using malpractice claims data to develop care transitions planning tools.

August 31, 2016

Development of an emergency department trigger tool using a systematic search and modified Delphi process.

July 13, 2016

Physician prescribing of opioids to patients at increased risk of overdose from benzodiazepine use in the United States.

May 16, 2018

An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions.

April 5, 2023

Rapid expansion of the Healing Emotional Lives of Peers program during COVID-19: a second victim peer support program for healthcare professionals.

January 31, 2024

Description and yield of current quality and safety review in selected US academic emergency departments.

August 30, 2017

Coronavirus disease 2019 (COVID-19) pandemic, central-line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI): the urgent need to refocus on hardwiring prevention efforts.

February 7, 2022

A study of the frequency and rationale for overriding allergy warnings in a computerized prescriber order entry system.

June 20, 2007

A systematic review of the performance characteristics of clinical event monitor signals used to detect adverse drug events in the hospital setting.

May 23, 2007

Avoiding wrong site surgery: a systematic review.

May 26, 2010

Guideline for opioid therapy and chronic noncancer pain.

May 31, 2017

Competencies for improving diagnosis: an interprofessional framework for education and training in health care.

August 28, 2019

Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System—MEADERS.

December 1, 2010

Emergency medicine physicians' perspectives on diagnostic accuracy in neurology: a qualitative study.

July 6, 2022

Hamilton Acute Pain Service Safety Study: using root cause analysis to reduce the incidence of adverse events.

April 2, 2014

Overriding drug-drug interaction alerts in clinical decision support systems: a scoping review.

September 7, 2022

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

September 23, 2020

Effect of standardized handoff curriculum on improved clinician preparedness in the intensive care unit: a stepped-wedge cluster randomized clinical trial.

January 24, 2018

Critical care clinicians' experiences of patient safety during the COVID-19 pandemic.

November 30, 2022

An intervention to decrease narcotic-related adverse drug events in children's hospitals.

October 29, 2008

The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial.

February 14, 2024

Operating room traffic as a modifiable risk factor for surgical site infection.

January 11, 2017

Exploring the intersection of structural racism and ageism in healthcare.

December 7, 2022

A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study.

January 8, 2014

The Lancet Commission on lessons for the future from the COVID-19 pandemic.

October 12, 2022

Expert consensus on currently accepted measures of harm.

September 9, 2020

Diagnostic errors that lead to inappropriate antimicrobial use.

June 3, 2015

Electronic health record-based prediction models for in-hospital adverse drug event diagnosis or prognosis: a systematic review.

March 29, 2023

Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.

April 12, 2017

The safety of inpatient health care.

January 25, 2023

Dual health care system use and high-risk prescribing in patients with dementia: a national cohort study.

December 14, 2016

Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016

March 3, 2017

The Safer Delivery of Surgical Services Program (S3): explaining its differential effectiveness and exploring implications for improving quality in complex systems.

February 24, 2016

The top patient safety strategies that can be encouraged for adoption now.

March 13, 2013

Association between language use and ICU transfer and serious adverse events in hospitalized pediatric patients who experience rapid response activation.

August 17, 2022

Hospital-readmission risk--isolating hospital effects from patient effects.

September 20, 2017

Outbreak investigation of COVID-19 among residents and staff of an independent and assisted living community for older adults in Seattle, Washington.

June 10, 2020

Safety culture in the operating room: variability among perioperative healthcare workers.

September 13, 2017

Intravenous chemotherapy compounding errors in a follow-up pan-Canadian observational study.

May 9, 2018

Impact of the nurse shortage on hospital patient care: comparative perspectives.

July 25, 2007

Low perfusion and missed diagnosis of hypoxemia by pulse oximetry in darkly pigmented skin: a prospective study.

March 6, 2024

Diagnostic reasoning in cardiovascular medicine.

January 19, 2022

A surgical safety checklist to reduce morbidity and mortality in a global population.

January 21, 2009

Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study.

August 19, 2020

Variation in emergency medical services workplace safety culture.

November 10, 2010

The Emergency Medical Services Safety Attitudes Questionnaire.

February 24, 2010

Association of surgical resident wellness with medical errors and patient outcomes.

May 6, 2020

Incidence, severity and preventability of medication-related visits to the emergency department: a prospective study.

June 18, 2008

The Diagnostic Error Index: a quality improvement initiative to identify and measure diagnostic errors.

February 10, 2021

Can medical record reviewers reliably identify errors and adverse events in the ED?

May 25, 2016

Family safety reporting in hospitalized children with medical complexity.

July 20, 2022

In their own words: safety and quality perspectives from families of hospitalized children with medical complexity.

September 6, 2023

American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology.

December 7, 2005

Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed.

August 10, 2022

An improvement approach to integrate teaching teams in the reporting of safety events.

May 10, 2017

Physicians' perspectives regarding prescription drug monitoring program use within the Department of Veterans Affairs: a multi-state qualitative study.

April 18, 2018

Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial.

June 22, 2022

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

March 1, 2023

Organisational culture: variation across hospitals and connection to patient safety climate.

January 5, 2011

Human factors in anaesthesia: a narrative review.

February 15, 2023

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis.

March 7, 2018

The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues.

November 12, 2014

5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data.

September 24, 2014

Related Resources

WebM&M Cases

Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.

April 24, 2024

Development and evaluation of I-PASS-to-PICU: a standard electronic template to improve referral communication for inter-facility transfers to the pediatric intensive care unit.

March 27, 2024

Learning from non-routine events and teamwork in intensive care units: challenges and opportunities.

February 28, 2024

A combined assessment tool of teamwork, communication, and workload in hospital procedural units.

January 17, 2024

Handoff tool improves transitions from the operating room to the neonatal intensive care unit.

November 8, 2023

Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit.

November 1, 2023

Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool.

September 27, 2023

Improving patients' intensive care admission through multidisciplinary simulation-based crisis resource management: a qualitative study.

September 20, 2023

Work system barriers and facilitators of a team health information technology.

September 13, 2023

Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study.

September 6, 2023

Improving handoffs in the perioperative environment: a conceptual framework of key theories, system factors, methods, and core interventions to ensure success.

July 19, 2023

So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization.

July 5, 2023

The effects of electronic nursing handover on patient safety in the general (non-COVID-19) and COVID-19 intensive care units: a quasi-experimental study.

June 14, 2023

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study.

June 7, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions.

April 5, 2023

Surgeons and systems working together to drive safety and quality.

March 29, 2023

Critical care teamwork in the future: the role of TeamSTEPPS in the COVID-19 pandemic and implications for the future.

March 15, 2023

Association between unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory failure survivors: a multicenter prospective cohort study.

February 15, 2023

Interprofessional team collaboration and work environment health in 68 US intensive care units.

November 30, 2022

Standardization of pediatric noncardiac operating room to intensive care unit handoffs improves communication and patient care.

October 5, 2022

WebM&M Cases

Miscommunication During the Interhospital Transport of a Critically Ill Child

August 31, 2022

Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes.

June 22, 2022

Communication patterns during routine patient care in a pediatric intensive care unit: the behavioral impact of in situ simulation.

May 11, 2022

Patient Safety Innovations

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

April 7, 2022

Patient harm and institutional avoidability of out-of-hours discharge from intensive care: an analysis using mixed methods.

March 23, 2022

Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.

March 23, 2022

Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients: a multicenter prospective cohort study.

March 2, 2022

Care transition of trauma patients: processes with articulation work before and after handoff.

February 16, 2022

February 2, 2022

See More About The Topic

Cardiothoracic Surgery

Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site