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Case Report/Simulation Scenario

Say What You Mean to Say: Improving Patient Handoffs in the Operating Room and Beyond

McQueen-Shadfar, Lauren MD; Taekman, Jeffrey MD

Author Information
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: August 2010 - Volume 5 - Issue 4 - p 248-253
doi: 10.1097/SIH.0b013e3181e3f234
  • Free



Patient Name: Patient J

Simulation Developers: Lauren McQueen-Shadfar, MD, and Jeffrey Taekman, MD

Date of Development: May 20, 2009

Appropriate for the following learning groups:

Faculty: CME

Residents (PGY): 1, 2, 3, 4, 5, 6, 7

Specialties: Anesthesiology, Nurse Anesthesia, Surgery, Critical Care, Emergency Medicine, Obstetrics

Medical Students (yr): 1, 2, 3, 4

Nurse Anesthesia Faculty: CEU

Nursing Students (yr): 1, 2


Educational Rationale

Improving communications among caregivers was an important 2008 Joint Commission National Patient Safety Goal. These initiatives are of great importance in light of the fact that communication problems were found to be the number one root cause of both anesthesia-related sentinel events and sentinel events across medical specialties.1 These events not only contribute to poor outcomes but also have profound economic consequence.2

An important component of improved communications is standardized hand-offs. The purpose of this scenario is to highlight two important patient safety issues within the field of anesthesiology—effective patient handoff communication and medication errors in the operating room (OR). As medication errors can result in death or major injury to patients, it remains of utmost importance that this issue not only be explored with a variety of healthcare professionals but also that methods to avoid their occurrence be taught and emphasized.

Learning Objectives

  • Verbalize factors that predispose to medications errors in the OR and explain how each can be prevented.
  • Manage and develop a differential diagnosis for persistent apnea/delayed emergence in the pediatric patient.
  • Conduct an effective, complete, and efficient patient handoff at the conclusion of the case.
  • Recite and explain the components of the TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) mnemonic for complete handoff: I PASS the BATON.

Guided Study Questions

  • What are the factors that contribute to medication errors in the OR and what measures should be taken to avoid them?
  • What clinical scenarios might lead to increased suspicion of a medication error as the root cause?
  • Provide a differential diagnosis for persistent apnea/delayed emergence in the pediatric patient.
  • Detail the components of an effective provider handoff of patient care, including information to be relayed and optimal environmental aspects.


Assessment Instruments



This simulation will require the following simulation equipment:

  • Pediatric mannequin (adult mannequin will suffice if pediatric size unavailable)
  • One simulation room
  • Two confederates (as an alternative, one person may act as both confederates and be simply introduced to the learner as each different personality as required by the simulation)
  • Figure
  • Supporting Files (cxr, ekg echo, assessment, handouts, etc)
  • None
  • Figure

Case Stem

You are an anesthesia provider at a local community hospital who is coming into the pediatric OR to relieve your colleague who has unexpectedly had to leave due to a family emergency. Your task is to receive handoff of the patient from your colleague, complete the case in the OR and transfer the patient to the Post Anesthesia Care Unit (PACU), giving appropriate handoff to the PACU nurse at the conclusion of the scenario (Table 1).

Table 1
Table 1:
Case Scenario
Table 1
Table 1:

Background and Briefing Information for Facilitator/Coordinator's Eyes Only

The learner in this scenario will be taking over for another anesthesia provider near the conclusion of an otherwise uncomplicated, routine outpatient surgery involving a 2-year-old boy undergoing laparoscopic inguinal herniorrhaphy. The learner is told that neuromuscular reversal has been given and that the surgery will conclude within the next 10 minutes. He/she will be instructed to complete the case and transfer the patient to the PACU, giving appropriate handoff to the PACU nurse at the conclusion of the scenario. The learner will find that the patient, however, will be persistently apneic, despite minimal opiate or other adjuvant anesthetic use during the case. He/she will need to develop a differential for persistent apnea/delayed emergence and, on surveying the medications given, find that additional neuromuscular blockade was given instead of appropriate reversal—a mistake made in an apparent “syringe swap.” At the conclusion of the case, the patient will be taken to the PACU where the learner will need to carry out a thorough and appropriate handover of patient care to the PACU nurse that includes the events of the surgery and reason for prolonged emergence. The purpose of this case is to highlight patient safety issues in the OR including medication errors and to teach appropriate handoff and communication techniques to further improve patient safety on arrival in the PACU.

Patient Data Background and Baseline State

Patient History

History of Present Illness.

The patient is a 2-year-old boy who has a 2-month history of right scrotal swelling discovered incidentally during his bath time. Examination and workup by his primary care provider was consistent with a right inguinal hernia, and thus the patient was referred to a local pediatric surgeon for definitive repair.

Medical History.

Born via spontaneous vaginal delivery at 39 weeks, Apgar scores 9/9. Mother received routine prenatal care, and the patient visits the pediatrician routinely for checkups. He had one episode of otitis media at approximately 6 months of age but has otherwise been healthy. Vaccinations are up to date and the patient has met all developmental milestones as predicted for age.

Surgical History.

No previous surgeries.

Review of Systems

Central nervous system: No headaches, focal weakness, has met all developmental milestones as expected for age.

Cardiovascular: Denies cyanosis, easy fatigability.

Pulmonary: Denies dyspnea, cough, wheezing. Has had runny nose in the past 2 days but denies fever.

Renal/hepatic: Denies dysuria, hematuria, olig- or polyuria.

Endocrine: Denies inappropriate weight gain/loss.

Heme/coag: Denies easy bruising/bleeding.

Current medications and allergies: No current medications, NKDA.

Physical Examination

General: Alert, healthy appearing, and active child who is interactive and playful.

Weight, Height: 81 cm; 13 kg.

Vital Signs: heart rate (HR), 100 bpm; blood pressure (BP), 100/70 mm Hg; respiratory rate (RR), 25; SpO2, 100% on room air; Temperature, Afebrile; head, ear, eyes, nose and throat/airway, no evidence of airway erythema. Mild coryza present. TM's clear. Mallampati I, Interincisor distance, 2 cm, full cervical range of motion.

Lungs: Clear to auscultation bilaterally, good air entry throughout.

Heart/cardiovascular: Regular rate and rhythm, no murmurs, rubs, gallops noted. Peripheral pulses 2+ in bilateral upper and lower extremities.

Laboratory, Radiology, and Other Relevant Studies

Hematocrit (HCT): 34%

Chest x-ray (CXR): Not obtained

EKG: Not obtained

Baseline Simulator State

Vitals: HR: 90 bpm; BP, 100/65 mm Hg; RR, 20; SpO2, 99%.

Neuro: Anesthetized, paralyzed patient.

Respiratory: Intubated and mechanically ventilated.

Cardiovascular: No baseline alterations.

Gastrointestinal: No alterations.

Genitourinary: No alterations.

Metabolic: No alterations.

Environmental: Workstation should be moderately “cluttered” (eg, oral and nasal airways, tongue depressors, medication vials, tape, in no particular order spread out on workstation with medication syringes placed among these items). Medication syringes available should be as follows:

  • One 5-mL syringe labeled “Fentanyl 50 μg/mL” with 4 mL of “drug” (water or saline) left in the syringe.
  • One 5-mL syringe labeled “Neostigmine 0.5 mg/mL” with 5 mL of “drug” in syringe.
  • One 3-mL syringe labeled “Glycopyrrolate 0.2 mg/mL” with 1 mL of “drug” in syringe.
  • One 3-mL syringe labeled “Rocuronium 10 mg/mL” that is empty.

A paper drug administration record should be made available with the following information given:

Inhalation induction with sevoflurane carried out followed by administration of 10 mg rocuronium after the intraveneous access is established.

Fentanyl 25 μg given after induction, an additional 25 μg given approximately 30 minutes after induction.

Glycopyrrolate 0.4 mg and neostigmine 1 mg given toward end of case.

A copy of the “Patient History” section noted above should also be available to the learner as the patient's history and physical if asked for at the conclusion of the scenario.


In 2006, 2007, and 2008, the Joint Commission put forth as one of their National Patient Safety Goals to “implement a standardized approach to hand off communication.”22 This likely stems in part from their estimation that from 1995 to 2005, more than 65% of sentinel events that were reported were the direct result of inadequate teamwork and communication.23 In the landmark report, “To Err is Human” put forth by the Institute of Medicine in 1999, the recommendation was made to healthcare organizations to implement evidenced-based and multidisciplinary teamwork and communication models similar to that used in other high stakes industries, such as nuclear power and aviation.24 In 2005, the TeamSTEPPS was piloted as the culmination of collaborative work between the US Department of Defense (DOD) and the US Agency of Healthcare Research and Quality. This program was formed after many years of devoted literature reviews and expert discussions centered on both DOD and non-DOD training programs, and the result is a curriculum that is supported by a broad research base both within healthcare and in other high-risk industries that is useful in part for improving communication, and thus patient safety, for healthcare organizations.25

It is well known that a variety of models exist that attempt to standardize the handoff process. A recent review identified more than 24 different handoff mnemonics published to date and concluded, however, that the literature available was not “of sufficient quality and quantity to synthesize into evidence-based recommendations.”26 Thus, the “appropriate” mnemonic is often that which includes the most relevant elements for a given handoff scenario. However, while the ASA Standards for Postanesthesia care state that a “verbal report” containing “information concerning the preoperative condition and the surgical/anesthetic course” should be provided to the PACU nurse, no particular structure to the handoff is explicitly outlined or recommended.27 In the instance of PACU handoffs, it is especially important to remember that often, a given care plan is already in place and in progress and will need appropriate re-evaluation and follow-up. For example, a patient who has just undergone an exploratory laparotomy with a large estimated blood loss may be brought to the PACU with colloid being infused and in need of follow-up laboratories to determine the need for transfusion. A common handoff mnemonic, “SBAR” does not provide a specific framework for handing over all of the necessary information. Although more detailed, TeamSTEPPS' “I PASS the BATON,” provides specific cues to draw attention to safety concerns, timing of specific actions, and ownership information, all of which are vitally important in the perioperative period where much about a patient may be in flux and requiring timely follow-up and action. It is for these reasons that this particular mnemonic was chosen for use in this scenario. Importantly, in teaching learners to use this mnemonic to strengthen the handoff process, it is imperative that the individual elements be emphasized, perhaps in a group debriefing session. At our institution, these elements would be discussed in further detail during the debriefing session that would take place at the conclusion of the scenario. It is at this time that the learners can reflect on the handoff they provided during the case and contrast it with that guided by the TeamSTEPPS mnemonic. Finally, at the conclusion of the debriefing, learners should have the opportunity to practice providing handoffs with each other using this model. As there are a number of items within the TeamSTEPPS mnemonic, the use of a cognitive aid may be helpful to learners as they familiarize themselves with the model and its implementation. The reader is directed to the Agency of Healthcare Research and Quality's TeamSTEPPS Tools website for an appropriate aid that is available to the public for use.28

In conclusion, the handoff of patient care between healthcare providers continues to be a tenuous time with much potential for ineffective communication and thus, potentially dangerous patient care. This simulation is meant to draw attention to this issue and guide the learner through a handoff scenario in which he/she must first discover and then disclose a medication error. This scenario emphasizes the use of a mnemonic to illustrate the provision of a structured framework around which a thorough, yet, concise handoff could be carried out. As the nature of healthcare delivery systems continue to change, we will likely continue to see an increase in handoffs of patient care, and for this reason, it continues to be vitally important that this event be appropriately practiced and carried out to avoid hazardous lapses in patient care.


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