In August 2023, three patients entered our operating rooms and procedural areas with incomplete or inaccurate information that could have resulted in patient harm.

A critical assessment of these cases through our Root Cause Analysis process identified communication gaps and staff’s interpretations of what was considered essential information as causative factors.

An interdisciplinary task force developed a checklist/handoff tool in order to improve communication and team building between periprocedural healthcare providers and to standardize the process and the essential information communicated prior to entry into the operating room.