… Jt Comm J Qual Patient Saf … Multiple handoffs during perioperative …

Structured handoffs are recognized as a method to ensure that complete, accurate information is shared between teams. This article describes the impact of the Handoffs and Transitions in Critical Care (HATRICC) study on accuracy and completeness of handoff before and after implementation of a structured handoff tool. Post-intervention, the accuracy and completeness of handoffs improved. Omissions, mortality, and length of intensive care unit (ICU) stay were reported in a 2019 study.

Anesthesiologists frequently hand off care of complex, often unstable patients, which can introduce patient safety risks. This systematic review examined the education components of studies seeking to improve anesthesiology handoffs. The authors identified marked heterogeneity in the use of established curriculum development best practices and concluded that more than half of the medical education interventions were of low quality. The authors identify challenges that could be addressed to improve future educational interventions.

Structured handoffs support appropriate communication between teams or departments when transferring responsibility for care. This meta-analysis aimed to determine if structured, standardized post-operative anesthesia handoffs improved provider, patient, organizational and handoff outcomes. Postoperative outcomes moved in a generally positive direction when compared with non-standardized handoffs. The authors suggest additional research into pre- and intra-operative handoffs is needed.

Root cause analysis (RCA) is a common method to investigate adverse events and identify contributing factors. To expand resident understanding of and participation in RCA, the authors developed simulated RCAs that were applicable to a broad set of specialties and included other healthcare professionals whose disciplines were involved in the event (e.g., nurses, pharmacists). After participating in the simulated RCAs, there was an increase in trainees understanding of RCA and intent to report adverse events.

The objective of this mixed methods study was to characterize training, practices, and preferences in interprofessional handoffs from the operating room to the intensive care unit (OR-to-ICU). Anesthesia residents, registered nurses, and advanced practice providers indicated that they had not received enough preparation for OR-to-ICU handoffs in their clinical education or on-the-job training. Clinicians from all professions noted a high value of interprofessional education in OR-to-ICU handoffs, especially during early degree programs would be beneficial.

The anesthesia community has been a leader in patient safety innovation for over four decades. This conference summary highlights presented content related to the conference theme of “preventing, detecting, and mitigating clinical deterioration in the perioperative period.” The results of a human-centered design analysis exploring tactics to reduce failure to rescue were summarized.

This study involving a survey of incoming interns found that nearly all medical interns believe that inadequate physical examination can lead to adverse events and that 45% have witnessed an adverse event due to inadequate examination. The authors propose a five-pronged intervention for improving physical examination training.

This study used a mixed-methods approach to characterize the impact of two academic fellowships in Quality Improvement Patient Safety (QIPS) to both graduates and their respective institutions. Students in these programs reported a positive impact of the fellowship on their careers, with nearly all being involved in QIPS administration, research or education upon graduation. Interviewed mentors also generally thought the fellowships were important and the resulting research had departmental, institutional and even national importance.

Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures and improve performance. This retrospective study of critical events in inpatient anesthesiology practice found that debriefing occurred in 49% of the incidents. Debriefs were less likely to occur when critical communication breakdowns were involved, and more than half of crisis events included at least one such breakdown. Interviews with care teams revealed that communication breakdowns present in some incidents impeded the subsequent debriefing process. The authors call for more consistent implementation of debriefing as a recommended patient safety process. A previous WebM&M commentary discussed an incident involving miscommunication between a surgeon and an anesthesiologist.

… Ann Surg … Handoffs represent a vulnerable time for patients … discussed implementation of a standardized handoff tool. … Lane-Fall MB, Pascual JL, Peifer HG, et al. A Partially Structured …

… Journal of surgical education … J Surg Educ … This qualitative study examined incident …

Although patient safety competency development is increasingly a goal of graduate medical education, skills to teach them are lacking. This project report describes the development, implementation, and outcomes of a curriculum developed to meet quality improvement and patient safety educational requirements. The approach included activities such as event reporting, root cause analysis, and disclosure simulation.

Most physicians pursue board certification through the American Board of Medical Specialties, and many subsequently enter maintenance of certification (MOC) programs in order to demonstrate a commitment to staying current in their field. Although board certification and MOC programs have traditionally focused on medical knowledge, this survey found that most MOC programs now incorporate patient safety and quality improvement content. However, the specific content and assessment methods varied widely between fields.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Physician engagement in quality and …

… journal of the American College of Medical Quality … Am J Med Qual … Engaging trainees in quality improvement efforts …

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Saf … Standardizing handoffs has been shown to improve …

This analysis of specialty-specific milestones for graduate medical education found that about 40% mentioned patient safety or quality improvement. Emphasis on patient safety and quality improvement skills varied by specialty. The authors conclude that patient safety concepts are addressed in graduate medical education competencies.

… Journal of the American Board of Family Medicine : JABFM … J Am Board Fam Med … Trigger tools employ electronic health …

… Journal of graduate medical education … J Grad Med Educ … It is critical to educate trainees about …