The Pre- and Post-Flight Debriefing: Standardization of the Handoff Process during Transitions of Care

●Communication has been cited as a leading factor in medical errors and adverse patient outcomes, especially during transitions of care.

●In the Fall of 2023, there were several incidents where critical information was not communicated during the handoff process.  These occurred during the transition of care, either when bringing a patient from the Critical Care Unit to the operating room or returning the patient from the operating room to the Critical Care Unit.

●When queried, a significant percentage of Anesthesia personnel, Critical Care nurses and physicians, and Post-Anesthesia Care Unit nurses raised concerns over the variability of information and process of handoffs.  They cited gaps in information that was communicated which resulted in compromised patient care and safety.

●A number of incidents were reported through our One Link Incident Reporting system at Jersey Shore University Medical Center.  Our Root Cause Analysis process identified communication issues as a causative factor in most of these safety events.

●A Task Force of Anesthesia personnel, Critical Care nurses representing each of our Critical Care units, PACU nurses, perioperative leaders, and Quality & Patient Safety Department representatives convened to establish a handoff tool and standardize the process of transitioning care between the operating room and our PACUs/ICUs.