Preventable medical errors are a frequent cause of harm for hospitalized patients.1 Recent evidence suggests that as many as 200,000 to 400,000 patient deaths occur as a result of errors each year.2 Lack of effective communication is a significant cause of these preventable errors,3 and poor-quality transfers of patient care are associated with adverse events.3–8 As a result, transfers of care have been a focus of attention for national regulatory agencies. The Joint Commission has reported that communication breakdowns were the leading cause of reported sentinel events between 1995 and 2006a and estimated that errors in communication at handoff or transfer of care may be implicated in as many as 80% of serious medical errors.b
The handoff of a patient from 1 clinician to another requires a transfer of information and responsibility.3,9,10 In the operating room, this handoff from 1 clinician to the next often occurs while there are many competing demands on attention, in an environment rampant with distractions. Handoffs have been described as “high-risk, error-prone patient care episodes” because there are a number of barriers to safe and effective transfer of care, including inaccurate or incomplete information transfer; lack of consistency, organization, and standardization; information overload; and distractions.11,12
In 2006, the Joint Commission made implementation of standardized handoffs a National Patient Safety Goal (2006 NPSG 2E). In the perioperative arena, most of the current literature focuses on the postoperative handoff,5,11,13,14 with several studies formally examining the impact of postoperative handoff tools.14–17 However, intraoperative handoffs may be another major source of communication failure, and little has been published about this crucial transfer of care. The risks of these handoffs have been recognized for many years. Standardization and development of an intraoperative handoff protocol was first suggested more than 30 years ago,18 and recent studies reflect a need for such a standardized process.4,12 A protocol for intraoperative relief was outlined by Cooper as far back as 1989,19 but the process of information transfer and retention during this critical juncture has remained largely unexplored. Many anesthesia practices still do not have structured intraoperative handoff protocols, despite the fact that several handoffs occur per day and sometimes per case in each operating room. A recent paper described the development of an electronic intraoperative handoff tool and called for the creation of measurement tools to demonstrate improvement in patient care as a result of use.20
To improve the intraoperative handoff process, and to help address the lack of evidence regarding problems that might occur with this handoff, we developed and introduced a simple, structured, easy-to-access electronic checklist in clinical practice, to be used between providers at the time of intraoperative transfer of care. As part of this quality improvement effort, we analyzed efficacy of the checklist, monitored its usage, and surveyed viewpoints of department members on the handoff process before and after implementation of the checklist.
As a quality improvement initiative undertaken at Massachusetts General Hospital, Boston, this project was submitted to the IRB; it was considered exempt from review. As such, it was not formally supervised by the IRB per its policies. The goal of this initiative was to improve the quality of the intraoperative transfer of patient care responsibilities (“handoff”) between anesthesiologists. Starting on October 2, 2012, we assessed the transfer and retention of clinical patient information at handoff using the assessment tools described below. On October 18, an electronic checklist was introduced, to be used on a voluntary basis as a framework to structure the handoff process. Assessment of intraoperative handoffs performed both with and without use of the checklist continued until January 25, 2013. All anesthesia providers involved in intraoperative transfers of care were included, namely: residents, fellows, certified registered nurse anesthesiologists (CRNAs), and faculty anesthesiologists.
Development of Handoff Checklist
A simple, structured checklist containing the smallest number of items thought essential during intraoperative handoff was developed by the authors, with the intent of implementation via the electronic anesthesia information management system (AIMS) (MetaVision; iMDSoft, Tel Aviv, Israel). The goal was to create a guide to prompt discussion and improve communication at the transfer of care rather than to provide an exhaustive list of data. The authors, all practicing clinical faculty anesthesiologists, designed the checklist by consensus about important elements in the end-of-shift operating room handoff based on collective clinical experience. Selected data entered into the AIMS before the handoff were prepopulated into specific fields of the checklist. A key consideration in the development of the checklist was to keep it short, limiting prepopulation to essential data, and consolidating other items of interest into a small number of fields (Fig. 1).
Access to the checklist was designed to fit into the normal handoff process used by clinicians. When the routine transfer of responsibility for a patient’s anesthetic care occurs, the primary anesthesiologists are required to document that transition in the AIMS. A button to access the checklist was created on the AIMS page used for this transition documentation. Pressing the button opened the checklist as a pop-up window. Either the outgoing or receiving anesthesiologist could prompt access to the checklist by pressing the button. All the fields shown in Figure 1 that contain data specific to the case (e.g., age, weight, and mask quality) were prepopulated. The only action that the providers could implement was to mark the checkboxes to the left of each field. Once all the checkboxes were marked, there was a color change from red to green in the bar across the top of the window (Fig. 1). Not all boxes needed to be marked for the checklist to be saved. Aside from addition of the checklist, there were no prescribed changes to the pre-existing verbal handoff process.
Development of Assessment Tools
An observational assessment tool was developed to gather data on the relay of information during handoff (Fig. 2). In addition to some basic information about the handoff, such as date, duration of handoff, and type of anesthesiologists involved in the handoff (trainee, CRNA, or faculty), 24 separate items were evaluated (Fig. 2).
To assess handoff receiver satisfaction and information retention, a posthandoff assessment tool containing 7 questions was developed (Fig. 3). Three subjective questions related to clarity of the information presented during handoff, satisfaction with discussion of intraoperative and postoperative concerns, and the perception of the receiver that the handoff was rushed. Four objective questions on amount of fluid administered, muscle relaxant used, antibiotic used, and timing of the next antibiotic dose, if applicable, were included to evaluate information relay and retention.
Introduction of the Checklist into Clinical Practice
Clinical use of the handoff checklist was initiated on October 18, 2012. During the following 2 weeks, e-mail notifications, presentations on departmental notice displays, announcements at departmental academic conferences, and personal instruction by the authors were given to familiarize providers with the checklist. Screenshots of the checklist (Fig. 1) and instructions on how to access and use it were shared, along with contact information for feedback and questions. It was emphasized that use of the checklist was voluntary, not mandatory. We did not promote use or awareness of the checklist beyond the initial introductory period.
Assessment of Handoffs
From October 2012 to January 2013, we identified permanent end-of-shift handoffs from the operating room dynamic schedule on the days when we were available. We then went to the corresponding operating room, introduced ourselves to the 2 anesthesia providers performing the handoff, indicated the purpose of our presence, and observed the handoff. When identifying the handoffs from the schedule, we had no knowledge of whether the checklist would be used or of the type or identity of anesthesia providers involved in the handoff.
For purposes of assessment, only permanent transfers of care were targeted as opposed to temporary transfers of care when the original anesthesiologist was expected to return (e.g., breaks). Although the observer recorded whether or not the checklist was used, the observer never encouraged use of the checklist, and the observation process was identical regardless of checklist use. Data were recorded on the observational assessment tool (Fig. 2) by the observer listening to the anesthesiologists as they conducted the handoff. Approximately 15 minutes after conclusion of the handoff and departure of the outgoing anesthesiologist, the observer returned to the room and administered the posthandoff assessment to the relieving anesthesiologist (Fig. 3).
After the collection of data, one author examined the electronic anesthesia record for each observed handoff to confirm which items were applicable. The frequency of information transfer and retention was calculated from denominator cases in which the item was applicable. For example, if vasopressors or muscle relaxants were not given during a case, this case was excluded from the calculation of information transfer for vasopressor or relaxant use because it would be inappropriate to expect information transfer for medications that were not administered.
Consequently, for items that were not applicable to each handoff assessed, frequencies of information transfer and retention were calculated relative only to the number of handoffs in which a given item applied, as documented from the anesthesia record.
Review of the electronic anesthesia records also allowed identification of the providers involved in 67 of the 69 handoffs (no identifying information about the providers involved in the handoff had been collected on the assessment tools, other than the type of provider). Only 2 provider pairs were sampled twice. Unique provider pairs performed all the remaining 63 handoffs. The majority of providers (86%) participated in only 1 or 2 handoffs. A minority of providers (14%) participated in 3 or more handoffs, but always with different partners.
We surveyed all department members with clinical privileges by intradepartmental electronic mail before and 10 months after introduction of the checklist. Survey reminders were sent 3 times within a period of 10 days using an Internet-based survey tool (SurveyMonkey Inc., Palo Alto, CA).
In both surveys, respondents were asked 3 questions pertaining to their experience with the end-of-shift intraoperative handoff. These questions were virtually identical to the subjective questions asked during the posthandoff assessment in the operating room (Fig. 3). These questions addressed general satisfaction with clarity of communication, discussion of perioperative concerns, and subjective perception that end-of-shift handoffs were rushed.
In the follow-up survey, respondents were asked 2 additional questions, namely how often they used the checklist and how useful they thought the checklist was. In both surveys, respondents were also asked to identify their provider type. Denominators to determine survey response rates were derived from departmental rosters of clinicians who worked in the operating room.
Assessment of Checklist Usage
Data on checklist usage were collected from the AIMS. To compute the frequency of checklist usage, we derived the number of permanent anesthesiologist handoffs from the billing compliance portion of the AIMS. We then queried the AIMS for checklists saved within ±30 minutes of the time stamp for transition of care. If no checklist was saved within that time window, we classified that handoff as having occurred without use of the checklist. If the checklist was saved, we classified the handoff as having occurred with the checklist regardless of whether some or all items were checked. If more than 1 checklist was saved, for example, because 1 checklist was completed for the anesthesiologist-to-anesthesiologist handoff and another for the supervising faculty anesthesiologists’ handoff, the handoff was classified as having occurred with the checklist. That handoff counted as 1 observation (despite having 2 checklists associated with it) toward the total number of handoffs performed with the checklist. Checklist use was computed as the ratio of number of handoffs with checklist over total number of handoffs per month.
Two-tailed Fisher exact test was used to compare frequencies of information transfer measured with the observational assessment tool (Fig. 2) and frequencies of information recall measured with the second part of the posthandoff assessment tool (Fig. 3) between handoffs performed with and without the checklist. This test was also used to analyze differences in handoff satisfaction rates between the prechecklist and postchecklist departmental surveys.
The χ2 test was used to compare categorical variables that were not classified as dichotomous, such as the provider composition of the survey populations (i.e., trainee, CRNA, and faculty anesthesiologist) and receiver anesthesiologist’s satisfaction between handoffs performed with and without the checklist.
P values <0.05 were considered statistically significant. To account for the effect of multiple statistical tests of the variables recorded with the assessment tools on the false-positive rate, we controlled the false discovery rate at 0.05. Consequently, some results for which the individual test yielded P <0.05 were considered not significant if the corresponding P value exceeded the false discovery rate criterion.
Upper and lower control limits for the proportion of handoffs performed using the checklist were calculated with quality control chart (p-chart) methodology applied to the monthly data from January 2013 to June 2013. These limits are based on 3 SDs from the mean proportion of handoffs performed with the checklist, calculated during the 6-month period.
Statistical analysis was performed with 2 software packages: GraphPad, La Jolla, CA, and SAS, SAS Institute Inc., Cary, NC.
Information Transfer and Retention
We assessed 30 handoffs performed without the checklist and 39 with the checklist. Twenty of the 30 handoffs without the checklist occurred before October 18, 2012, i.e., before introduction of the checklist. There were 29 posthandoff assessments completed for handoffs performed without the checklist (1 posthandoff assessment was not done) and 37 posthandoff assessments for handoffs performed with the checklist (2 posthandoff assessments were misplaced). Overall, relay and retention of specific information improved with use of the checklist (Tables 1 and 2). The major improvements occurred in 2 main categories: intraoperative medications and fluid balance, and communication.
The use of several intraoperative medications was discussed more frequently when the checklist was used (Table 1). This effect was particularly pronounced for vasopressors, antibiotics, and antiemetics. The percentage of handoffs in which use of these drugs was discussed increased from 44% to 85% for vasopressors (P = 0.008), from 63% to 97% for antibiotics (P < 0.001), and from 15% to 46% for antiemetics (P = 0.015). Similarly, information about intravascular lines and fluid balance was more frequently discussed when the checklist was used. Information regarding mask ventilation and laryngoscopic view tended to be relayed more frequently with the checklist (100% and 90% of the times, respectively) although these items did not reach statistical significance.
This improved information transfer was associated with a larger percentage of anesthesiologists being able to accurately recall critical patient information after the handoff had occurred (Table 2). The percentage of anesthesiologists who knew the intraoperative antibiotic given and timing of next dose grew significantly with use of the checklist. There were also significant increases in the percentage of anesthesiologists who knew the muscle relaxant and the amount of fluids that had been administered. When this analysis of key end points was repeated comparing the subset of “without checklist” observations performed before checklist introduction with those performed with the checklist, there was still a significant improvement in the percentage of anesthesiologists who knew the amount of fluid (80% [n = 20] vs 97% [n = 37], P = 0.046), the muscle relaxant (69% [n = 16] vs 97% [n = 29], P = 0.017), and antibiotic administered (74% [n = 19] vs 97% [n = 32], P = 0.022) in the group that used the checklist. The timing of antibiotic readministration was also more frequently known among checklist users than before the checklist was introduced although the difference did not reach statistical significance (53% [n = 19] vs 75% [n = 32], P = 0.13).
In addition to fostering transmission and retention of specific information, use of the checklist was associated with improved interpersonal communication both within the anesthesia team and within the operative team as a whole. Discussion of potential areas of concern and postoperative plan between outgoing and incoming providers increased from approximately half to more than 90% of handoffs with use of the checklist (Table 1). Introduction of the incoming anesthesiologist to the rest of the operative team also improved (3% vs 51%, P < 0.001).
Satisfaction with Handoff
In terms of subjective satisfaction with the quality of handoff, there was a trend toward improvement in perceived quality of communication and discussion of perioperative concerns although these did not reach statistical significance (Table 3). There was a significant (P = 0.045) reduction in the perception that the handoff was rushed when the checklist was used, despite the fact that the duration of handoffs performed with and without the checklist was not significantly different (5 ± 2 vs 4 ± 3 minutes, respectively).
Departmental Survey Results
The responses to the prechecklist and postchecklist surveys are shown in Table 4. Response rates for all clinicians, faculty anesthesiologists, trainees (residents and fellows), and CRNAs were as follows: 150 of 262 (57.3%), 73 of 120 (60.8%), 47 of 86 (54.7%), and 30 of 56 (53.6%) in the prechecklist survey; and 133 of 266 (50.0%), 44 of 118 (37.3%), 47 of 88 (53.4%), and 42 of 60 (70.0%) in the postchecklist survey. Because the distribution of respondents by provider type differed between the 2 samples of respondents (P = 0.017), subanalyses for the faculty anesthesiologist, trainee, and CRNA groups were also performed (Table 4).
Notably, all provider groups reported better satisfaction with the quality of communication at the end-of-shift intraoperative transfer of care in the postchecklist survey. Trainees and CRNAs also reported improved identification of perioperative concerns, and CRNAs felt that the handoff was rushed less frequently (Table 4).
Eighty-eight respondents (66.2%) reported using the checklist in at least two-thirds of their handoffs, and 86 of these (97.7%) felt the checklist was very or somewhat useful. Forty-five respondents (33.8%) reported using the checklist less than two-thirds of the time, but 31 of these (68.9%) found it useful nonetheless.
Furthermore, respondents who reported using the checklist in at least two-thirds of their handoffs reported higher satisfaction with quality of communication at handoff (P = 0.003) and identification of perioperative concerns (P = 0.012) than respondents who used it less frequently. Similarly, respondents who thought the checklist was useful also reported higher satisfaction with quality of communication (P < 0.001) and identification of perioperative concerns (P = 0.003).
Handoff Checklist Adoption
From October 2012 to January 2013, adoption of the checklist increased to 60% of intraoperative handoffs. Checklist use occurred in 74% of handoffs (99% control limits: 58% to 75%) 8 months after introduction of the checklist (Fig. 4).
We developed and introduced a simple, standardized, easily accessible electronic checklist into clinical practice for intraoperative transfer of care. Use of this checklist significantly increased information relay and retention and improved communication. In general, clinicians expressed high levels of satisfaction with the checklist and voluntarily continued to use it with increasing frequency over a sustained period of time.
Information Transfer and Retention
Information transfer at the time of handoff was poor before introduction of the checklist. This is not surprising because the transfer of care comes after a 10-hour workday, interspersed with few breaks, and a large quantity of information must be relayed. In the observed handoffs, checklist use improved information transfer and retention. This improvement in information transfer and retention is a sign of improved handoff communication and may result in decreased errors. Other studies have shown the utility of checklists in reducing medical errors and improving patient safety. The introduction of a checklist-based intervention in intensive care units nearly eliminated catheter-related bloodstream infections in Michigan.21 As part of the Safe Surgery Saves Lives campaign of the World Health Organization, a structured checklist used before induction of anesthesia, before incision, and before the patient leaves the operating room reduced mortality and complications by more than 35%.22
It is likely that some of the items on the checklist showed significant increase in transfer as a result of being brought forward from other parts of the anesthesia record, a unique benefit of an AIMS-based checklist. Studies of electronic health record–based tools in other areas of medicine have shown benefit in improving information transfer and reducing adverse events.23–25 Although the development of an AIMS-based handoff tool has been described recently,20 there has otherwise been limited evidence with regard to perioperative handoffs.11,26,27 With use of the electronic checklist, information for patient weight, airway management, IV access, estimated blood loss, urine output, and antibiotic administration was displayed from previous entries in the record, and several of these items showed statistically significant improvements in information transfer with use of the checklist.
Vasopressor administration, an item on the checklist that was not prepopulated with data from the anesthesia record, is worth noting. When vasopressors were administered during a case, only 44% of handoffs contained information about these drugs if the checklist was not used, versus 85% of handoffs if it was. This finding, along with similar results for antiemetics and other items, suggests that use of the checklist promoted information relay even without specifically displaying information previously entered in the record.
In addition to augmenting transfer of the details of anesthetic care, information retention was improved with use of the checklist. When queried about fluid administration, muscle relaxants, and antibiotic dosing 15 minutes after the handoff, incoming anesthesiologists were more likely to know the correct answer when they had used the checklist. This is important because accurate information transfer and retention may have implications for postoperative outcomes. For example, studies have shown that failure to adequately reverse neuromuscular blockade can increase the likelihood of postoperative respiratory complications and increase postanesthesia recovery length of stay.28,29 In addition, timely redosing of prophylactic antibiotics has been recommended to reduce the incidence of surgical site infections when surgical procedure length exceeds 2 half-lives of the drug or when there has been excessive blood loss.30,31
Effect of Checklist on Communication
These results suggest that use of the checklist was also associated with improved communication for items such as potential areas of concern and postoperative plans, which were not intended to increase the transfer of discrete data, but rather to prompt discussion between clinicians, encouraging bilateral communication as opposed to a 1-way relay of facts.
Furthermore, introduction of the incoming anesthesia provider to the operative team increased substantially with use of the handoff checklist. This is an element of the World Health Organization Surgical Safety Checklist,22 and although considerable gains were made, the fact that nearly half of the handoffs still failed to include an introduction of the incoming provider suggests there is room for further improvement.
The departmental survey confirmed the findings of the handoff assessments. Clinicians who reported using the checklist more frequently also felt that perioperative concerns were better identified and the quality of communication was better than clinicians who used the checklist less frequently. Eight months after introduction of the checklist, use of the checklist remained high, suggesting that providers have found it useful. In fact, handoff checklist use was recently chosen as an internal quality incentive measure, reiterating the belief of our department in the value of the checklist.
Duration of Handoff
Others have found that after introduction of a handoff protocol, handoff quality and teamwork were improved without increasing the duration of the handoff.14 Our results confirm this finding in the operating room setting. Information transfer and retention improved without increasing the duration of the handoff. Furthermore, there was a significant reduction in the perception of the incoming anesthesiologist that the handoff was rushed when the checklist was used (Table 3).
This study has a number of key limitations. The sample size is limited. Consequently, some of our findings demonstrated a strong trend but lacked statistical significance (Table 1). However, it is noteworthy that the key end points showed significant differences even when the comparison was restricted to the smaller sample of prechecklist observations.
Our results come from a nonrandomized sample of observations. Although the observational design is certainly a limitation, it is important to emphasize that the observers did not have previous knowledge of whether the checklist would be used in any given handoff or of the identity or type of providers doing the handoff.
We were the observers and assessors of the handoffs, introducing the possibility of observer bias given the potential interest in a positive outcome. To reduce the effect of this bias, observations were conducted with standardized objective data collection tools (Figs. 2 and 3). Furthermore, the key end points (Table 2) hinged on responses that did not leave much room for subjective interpretation. These objective tools also served to minimize any interobserver variation in the assessments.
This study focused only on the permanent end-of-shift handoff between anesthesia providers. Temporary handoffs for breaks are more common and may represent temporary gaps in knowledge of the patient by the relieving provider, given their transient nature. Expanding use of the checklist to these temporary handoffs may be an important area for future investigation.
Finally, the presence of a Hawthorne effect, namely that the quality of handoffs was affected by the mere presence of the observers, is a possibility. However, given that handoffs with and without the checklist were observed in the same fashion, this effect should not have differentially affected the results.
The use of a structured AIMS-based handoff checklist during intraoperative transfer of care improved relay and retention of critical information. With checklist usage sustained at nearly 75% of handoffs, clinicians felt that quality of communication and identification of perioperative concerns at the end-of-shift handoff were significantly better than before introduction of the checklist. These results suggest that use of a simple intraoperative handoff checklist can improve the quality of communication.
Name: Aalok V. Agarwala, MD, MBA.
Contribution: This author participated in the design of the study, data collection, data analysis, and writing of the manuscript.
Attestation: Aalok V. Agarwala approved the final manuscript. He attests to the integrity of the original data and the analysis reported in this manuscript.
Name: Paul G. Firth, MB, ChB.
Contribution: This author participated in the design of the study, data collection, data analysis, and writing of the manuscript.
Attestation: Paul G. Firth approved the final manuscript. He attests to the integrity of the original data and the analysis reported in this manuscript.
Name: Meredith A. Albrecht, MD, PhD.
Contribution: This author participated in the design of the study, data collection, data analysis, and revision of the manuscript.
Attestation: Meredith A. Albrecht approved the final manuscript. She attests to the integrity of the original data and the analysis reported in this manuscript.
Name: Lisa Warren, MD.
Contribution: This author participated in the design of the study, data collection, and revision of the manuscript.
Attestation: Lisa Warren approved the final manuscript. She attests to the integrity of the original data reported in this manuscript.
Name: Guido Musch, MD.
Contribution: This author participated in the design of the study, data collection, data analysis, and writing of the manuscript.
Attestation: Guido Musch approved the final manuscript. He attests to the integrity of the original data and the analysis reported in this manuscript and is the archival author.
This manuscript was handled by: Sorin J. Brull, MD, FCARCSI (Hon.).
The authors thank Eva A. Cassedy, BA, Clinical Research Assistant, and K. Y. Trudy Poon, MS, Biostatistician, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, for assistance with data entry and data analysis; Karen Y. G. Kan, MHSc, Clinical Engineer, Kayla R. Pagel, BS, Clinical Systems Analyst, Lauren N. Smith, Business Intelligence Developer, and Morgan M. Templeton, B Eng, Clinical Systems Analyst, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, for assistance with implementation of the electronic checklist; Robert S. Gibbons, PhD, Sloan Distinguished Professor of Management, Sloan School of Management and Professor of Organizational Economics, Department of Economics, MIT Sloan School of Management, Cambridge, Massachusetts, for his guidance in advancing this project from concept through implementation; Retsef Levi, PhD, J. Spencer Standish (1945) Professor of Management, Operations Management Group, MIT Sloan School of Management, Cambridge, Massachusetts, for his advice; Jeffrey B. Cooper, PhD, Professor of Anaesthesia, and Jenny W. Rudolph, PhD, Assistant Professor of Anaesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, for their groundbreaking work in this field and for their help in revising the manuscript; and Elizabeth A. Martinez, MD, MPH,c Associate Professor of Anaesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, for her advice, support and inspiration of this project.
a Joint Commission Center for Transforming Healthcare Web site. Available at: http://www.centerfortransforminghealthcare.org/assets/4/6/CTH_Hand-off_commun_set_final_2010.pdf. Accessed September 25, 2013.
b Joint Commission Center for Transforming Healthcare Web site. Available at: http://www.centerfortransforminghealthcare.org/projects/detail.aspx?Project=1. Accessed September 25, 2013.
1. Kohn LT, Corrigan J, Donaldson MS To Err Is Human: Building a Safer Health System. 2000 Washington, D.C. National Academy Press
2. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9:122–8
3. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80:1094–9
4. Jayaswal S, Berry L, Leopold R, Hart SR, Scuderi-Porter H, Digiovanni N, Phillips A. Evaluating safety of handoffs between anesthesia care providers. Ochsner J. 2011;11:99–101
5. Kitch BT, Cooper JB, Zapol WM, Marder JE, Karson A, Hutter M, Campbell EG. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34:563–70
6. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14:401–7
7. Borowitz SM, Waggoner-Fountain LA, Bass EJ, Sledd RM. Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey. Qual Saf Health Care. 2008;17:6–10
8. Sabir N, Yentis SM, Holdcroft A. A national survey of obstetric anaesthetic handovers. Anaesthesia. 2006;61:376–80
9. Jeffcott SA, Evans SM, Cameron PA, Chin GS, Ibrahim JE. Improving measurement in clinical handover. Qual Saf Health Care. 2009;18:272–7
10. Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care. 2010;19:493–7
11. Segall N, Bonifacio AS, Schroeder RA, Barbeito A, Rogers D, Thornlow DK, Emery J, Kellum S, Wright MC, Mark JBDurham VA Patient Safety Center of Inquiry. . Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analg. 2012;115:102–15
12. Horn J, Bell MD, Moss E. Handover of responsibility for the anaesthetised patient—opinion and practice. Anaesthesia. 2004;59:658–63
13. Nagpal K, Abboudi M, Fischler L, Schmidt T, Vats A, Manchanda C, Sevdalis N, Scheidegger D, Vincent C, Moorthy K. Evaluation of postoperative handover using a tool to assess information transfer and teamwork. Ann Surg. 2011;253:831–7
14. Catchpole KR, de Leval MR, McEwan A, Pigott N, Elliott MJ, McQuillan A, MacDonald C, Goldman AJ. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007;17:470–8
15. Zavalkoff SR, Razack SI, Lavoie J, Dancea AB. Handover after pediatric heart surgery: a simple tool improves information exchange. Pediatr Crit Care Med. 2011;12:309–13
16. Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med. 2011;12:304–8
17. Mistry KP, Jaggers J, Lodge AJ, Alton M, Mericle JM, Frush KS, Meliones JNHenriksen K, Battles JB, Keyes MA, Grady ML. Using six sigma(R) methodology to improve handoff communication in high-risk patients. In: Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). 2008 Rockville, MD Agency for Healthcare Research and Quality
18. Cooper JB, Long CD, Newbower RS, Philip JH. Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology. 1982;56:456–61
19. Cooper JB. Do short breaks increase or decrease anesthetic risk? J Clin Anesth. 1989;1:228–31
20. Tan JA, Helsten D. Intraoperative handoffs. Int Anesthesiol Clin. 2013;51:31–42
21. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–32
22. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AASafe Surgery Saves Lives Study Group. . A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491–9
23. Cheah LP, Amott DH, Pollard J, Watters DA. Electronic medical handover: towards safer medical care. Med J Aust. 2005;183:369–72
24. Petersen LA, Orav EJ, Teich JM, O’Neil AC, Brennan TA. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Jt Comm J Qual Improv. 1998;24:77–87
25. Raptis DA, Fernandes C, Chua W, Boulos PB. Electronic software significantly improves quality of handover in a London teaching hospital. Health Informatics J. 2009;15:191–8
26. Kim SW, Maturo S, Dwyer D, Monash B, Yager PH, Zanger K, Hartnick CJ. Interdisciplinary development and implementation of communication checklist for postoperative management of pediatric airway patients. Otolaryngol Head Neck Surg. 2012;146:129–34
27. Meyer-Bender A, Spitz R, Pollwein B. The anaesthetic report: custom-made printouts from anaesthesia-information-management-systems using extensible stylesheet language transformation. J Clin Monit Comput. 2010;24:51–60
28. Grosse-Sundrup M, Henneman JP, Sandberg WS, Bateman BT, Uribe JV, Nguyen NT, Ehrenfeld JM, Martinez EA, Kurth T, Eikermann M. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ. 2012;345:e6329
29. Butterly A, Bittner EA, George E, Sandberg WS, Eikermann M, Schmidt U. Postoperative residual curarization from intermediate-acting neuromuscular blocking agents delays recovery room discharge. Br J Anaesth. 2010;105:304–9
30. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RAAmerican Society of Health-System Pharmacists; Infectious Disease Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. . Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70:195–283
31. Zanetti G, Giardina R, Platt R. Intraoperative redosing of cefazolin and risk for surgical site infection in cardiac surgery. Emerg Infect Dis. 2001;7:828–31