Communication failures are a significant cause of preventable medical errors, and poor quality handoffs are associated with adverse events. Dr. Guido Musch, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, and colleagues developed and implemented a simple electronic checklist to improve communication during intraoperative transfer of care between anesthetists. The results of their quality improvement initiative are published in this month’s issue of Anesthesia & Analgesia and discussed in the article titled “An Electronic Checklist Improves Transfer and Retention of Critical Information at Intraoperative Handoff of Care.”
The authors performed a prospective observational assessment to compare transfer and retention of critical patient information between the outgoing and incoming anesthetist before and after introduction of the checklist. A secondary analysis of checklist usage and clinician satisfaction was also performed.
The authors found significant improvements in the frequency of critical information transfer and retention with checklist use, specifically with regard to medication administration, fluid management, and communication about intraoperative areas of concern and postoperative planning. Clinicians who used the checklist (sustained at nearly 75% of handoffs 8 months after introduction) reported higher satisfaction with the quality of communication at handoff.
Sentinel events and communication breakdowns are related. This study’s sample size was limited. Hopefully this study can be replicated at many institutions and the findings will be similar.