A novel process audit for standardized perioperative handoff protocols.

Vinay Pallekonda; Adam T Scholl; George M McKelvey; Hassan Amhaz; Deanna Essa; Spurthy Narreddy; Jens Tan; Mark Templonuevo; Sasha Ramirez; Michelle A Petrovic

Commentary

A novel process audit for standardized perioperative handoff protocols.

November 1, 2017

Pallekonda V, Scholl AT, McKelvey GM, et al. Jt Comm J Qual Patient Saf. 2017;43(11):611-618.

View more articles from the same authors.

Standardizing handoffs is a recommended strategy to reduce error. This commentary describes a tool developed to support handoffs from the operating room. The authors discuss how to audit handoff activities to ensure the tool is being used correctly.

PubMed citation

Available at

Related Resources From the Same Author(s)

Why we need a single definition of disruptive behavior.

June 27, 2018

Implementing a perioperative handoff tool to improve postprocedural patient transfers.

March 7, 2012

Intraoperative patient information handover between anesthesia providers.

November 5, 2014

Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs.

February 29, 2012

The rise of the medical scribe industry: implications for the advancement of electronic health records.

April 15, 2015

Banning the handshake from the health care setting.

May 28, 2014

Impact and culture change after the implementation of a preprocedural checklist in an interventional radiology department.

October 7, 2015

Bedside shift reports: what does the evidence say?

September 24, 2014

A process for analysis of sentinel events due to health care–associated infection.

November 28, 2007

Debriefing after critical incidents for anaesthetic trainees.

January 25, 2006

Drug and opioid-involved overdose deaths- United States, 2013-2017.

January 23, 2019

Readiness for organisational change among general practice staff.

April 28, 2010

A prospective study of suicide screening tools and their association with near-term adverse events in the ED.

September 30, 2015

Tablet-splitting: a common yet not so innocent practice.

January 19, 2011

Use of simulation to assess electronic health record safety in the intensive care unit: a pilot study.

April 24, 2013

Burnout and satisfaction with work-life balance among US physicians relative to the general US population.

September 12, 2012

Help your patient "get" what you just said: a health literacy guide.

June 13, 2012

A method for measuring system safety and latent errors associated with pediatric procedural sedation.

July 27, 2005

e-Prescribing: characterisation of patient safety hazards in community pharmacies using a sociotechnical systems approach.

July 31, 2013

E-prescribing: a focused review and new approach to addressing safety in pharmacies and primary care.

October 31, 2012

Retail pharmacy staff perceptions of design strengths and weaknesses of electronic prescribing.

August 1, 2012

Exploring information chaos in community pharmacy handoffs.

March 5, 2014

Pediatric weight errors and resultant medication dosing errors in the emergency department.

November 22, 2017

Strategies to reduce the risk of iatrogenic illness in complex older adults.

May 15, 2013

Exploring physician perspectives of residency holdover handoffs: a qualitative study to understand an increasingly important type of handoff.

August 2, 2017

How do community pharmacies recover from e-prescription errors?

January 7, 2015

E-prescribing errors in community pharmacies: exploring consequences and contributing factors.

April 16, 2014

The medical emergency team as a safety net.

November 8, 2006

From heroism to safe design: leveraging technology.

February 12, 2014

Minimizing electronic health record patient–note mismatches.

May 18, 2011

The importance of preparation for doctors' handovers in an acute medical assessment unit: a hierarchical task analysis.

February 29, 2012

Doctors' handovers in hospitals: a literature review.

March 2, 2011

Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations for orthopedic trauma patients.

February 6, 2013

I-PSI: short- and long-term efficacy of a comprehensive initiative to promote patient safety event reporting by trainees.

August 25, 2021

Association of resident fatigue and distress with perceived medical errors.

September 30, 2009

Quality of handoffs in community pharmacies.

May 10, 2017

Association between mobile telephone interruptions and medication administration errors in a pediatric intensive care unit.

January 15, 2020

Apology laws and malpractice liability: what have we learned?

July 8, 2020

Seen through the patients' eyes: safety of chronic illness care.

December 13, 2017

Innovative patient safety curriculum using iPad game (PASSED) improved patient safety concepts in undergraduate medical students.

September 21, 2016

Evaluation of patient safety culture in community pharmacies.

February 7, 2018

The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery.

March 29, 2012

Psychometric properties of the AHRQ Community Pharmacy Survey on Patient Safety Culture: a factor analysis.

May 11, 2016

Proceed with reasonable care: when legal principles inform training to prevent harm during the childbirth.

February 9, 2022

The first U.S. study on nurses' evidence-based practice competencies indicates major deficits that threaten healthcare quality, safety, and patient outcomes.

April 25, 2018

Increases in drug and opioid overdose deaths—United States, 2000–2015.

November 9, 2016

Retained foreign bodies: risk and outcomes at the national level.

May 13, 2015

Effects of sleep inertia on cognition.

January 25, 2006

February 13, 2008

Implementation of safeguards to improve patient safety in chemotherapy.

September 20, 2017

The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study.

August 24, 2022

Cold debriefings after in-hospital cardiac arrest in an international pediatric resuscitation quality improvement collaborative.

September 2, 2020

Family safety reporting in medically complex children: parent, staff, and leader perspectives.

July 6, 2022

Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events.

December 3, 2008

Managing competing organizational priorities in clinical handover across organizational boundaries.

January 21, 2015

Patient race and opioid misuse history influence provider risk perceptions for future opioid-related problems.

November 4, 2020

Duty hour reform in a shifting medical landscape.

April 24, 2013

Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients.

March 7, 2018

In the eye of the storm: the role of the pharmacist in medication safety during the COVID-19 pandemic at an urban teaching hospital.

December 23, 2020

Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes.

January 25, 2012

Does simulation improve patient safety?: self-efficacy, competence, operational performance, and patient safety.

July 18, 2007

The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.

May 6, 2009

Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals.

October 24, 2012

Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis.

November 18, 2020

Pediatric emergency department discharge prescriptions requiring pharmacy clarification.

August 5, 2015

Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis.

May 10, 2006

Development of a pragmatic measure for evaluating and optimizing rapid response systems.

March 29, 2012

Documentation of clinical review and vital signs after major surgery.

October 29, 2008

Social disparities in patient safety in primary care: a systematic review.

August 22, 2018

Optimizing situation awareness to reduce emergency transfers in hospitalized children.

October 20, 2021

Associations between national board exam performance and residency program emphasis on patient safety and interprofessional teamwork.

September 11, 2019

Decreasing handoff-related care failures in children's hospitals.

August 13, 2014

Systematic literature review on the effectiveness and safety of paediatric hospital-at-home care as a substitute for hospital care.

May 17, 2023

The safe day call: reducing silos in health care through frontline risk assessment.

September 24, 2014

A novel tool for organisational learning and its impact on safety culture in a hospital dispensary.

June 20, 2012

Effect of patient-centred bedside rounds on hospitalised patients' decision control, activation and satisfaction with care.

January 6, 2016

The role of housestaff in implementing medication reconciliation on admission at an academic medical center.

June 16, 2010

Pediatric radiology malpractice claims—characteristics and comparison to adult radiology claims.

July 12, 2017

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

November 17, 2010

Assessment of the global trigger tool to measure, monitor and evaluate patient safety in cancer patients: reliability concerns are raised.

March 20, 2013

Persisting high rates of omissions during anesthesia induction are decreased by utilization of a pre- & post-induction checklist.

February 1, 2023

Primary care physicians' willingness to disclose oncology errors involving multiple providers to patients.

November 25, 2015

Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis.

March 28, 2007

Risk factors for adverse events in emergency department procedural sedation for children.

October 25, 2017

Learning to overcome hierarchical pressures to achieve safer patient care: an interprofessional simulation for nursing, medical, and physician assistant students.

September 6, 2017

Containing COVID-19 in the emergency department: the role of improved case detection and segregation of suspect cases.

June 10, 2020

Collective intelligence meets medical decision-making: the collective outperforms the best radiologist.

September 9, 2015

Checklists to prevent diagnostic errors: a pilot randomized controlled trial.

July 8, 2015

Prevention of intravenous drug incompatibilities in an intensive care unit.

October 22, 2008

Analysis of deaths related to anesthesia in the period 1996-2004 from closed claims registered by the Danish Patient Insurance Association.

May 30, 2007

Impact of computerized orders for pediatric continuous drug infusions on detecting infusion pump programming errors: a simulated study.

June 16, 2010

Preventing harm in the ICU—building a culture of safety and engaging patients and families.

July 12, 2017

Moral distress in intensive care unit personnel is not consistently associated with adverse medication events and other adverse events

October 16, 2019

Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled study.

April 29, 2015

Nontechnical skills in pediatric surgery: factors influencing operative performance.

April 13, 2016

The patient's right to safety—improving the quality of care through litigation against hospitals.

May 17, 2006

National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA.

July 17, 2013

Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) tool.

June 15, 2016

Implementing the clinical occurrence reporting and learning system: a double-loop learning incident reporting system in long-term care.

March 24, 2021

Improving safety through speaking up: an ethical and financial imperative.

July 24, 2019

Related Resources

Potential uses of AI for perioperative nursing handoffs: a qualitative study.

April 12, 2023

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

April 5, 2023

WebM&M Cases

False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.

October 27, 2022

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

June 1, 2022

What are we missing? The quality of intraoperative handover before and after introduction of a checklist.

April 6, 2022

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

February 16, 2022

Influence of perioperative handoffs on complications and outcomes.

November 17, 2021

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation.

October 20, 2021

An observational study of postoperative handoff standardization failures.

June 23, 2021

Interprofessional training and communication practices among clinicians in the postoperative ICU handoff.

April 28, 2021

Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs.

March 10, 2021

Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes.

January 20, 2021

Impact of staff turnover during cardiac surgical procedures.

February 12, 2020

I-PASS mentored implementation handoff curriculum: champion training materials.

March 13, 2019

A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study.

February 6, 2019

Using a potentially aggressive/violent patient huddle to improve health care safety.

January 30, 2019

Implementing bedside handoff in the emergency department: a practice improvement project.

January 23, 2019

Perioperative medication errors: uncovering risk from behind the drapes.

January 16, 2019

Developing a standard handoff process for operating room–to-ICU transitions: multidisciplinary clinician perspectives from the Handoffs and Transitions in Critical Care (HATRICC) study.

August 1, 2018

A call to bridge across silos during care transitions.

May 30, 2018

Innovative approach to reconstruct bedside handoff: using simple rules of complexity science to promote partnership with patients.

May 30, 2018

Improving patient safety in public hospitals: developing standard measures to track medical errors and process breakdowns.

April 4, 2018

Identifying what is known about improving operating room to intensive care handovers: a scoping review.

February 28, 2018

Safe handover.

November 22, 2017

A novel ICU hand-over tool: the glass door of the patient room.

November 8, 2017

Saying goodbye.

October 18, 2017

Care transitions know-how not just for clinicians.

October 11, 2017

Inadequate hand-off communication.

September 20, 2017

Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME.

August 30, 2017

Structured patient handoffs: the movement toward adverse event reduction in the perioperative unit.

August 30, 2017

See More About The Topic

Hospitals

Health Care Providers

Surgery

Discontinuities, Gaps, and Hand-Off Problems

Epidemiology of Errors and Adverse Events

A novel process audit for standardized perioperative handoff protocols.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

A novel process audit for standardized perioperative handoff protocols.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

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