Improving the safety of patient handovers

posted December 7th, 2009

Patients who must be moved from the OR to an ICU are at increased risk for adverse events because of their vulnerable medical conditions and the complexity of coordination and communication between various caregivers during the handover. A group of enterprising clinicians at the Durham VA have been working together to make the handover process run more smoothly.

“As with so many problems in life, communication is the root cause of most difficulties that occur during patient handovers,” said Jonathan Mark, M.D., Professor of Anesthesiology at Duke, and Chief of Anesthesiology Service at the Durham VA. “We took this on because we recognized opportunities to provide safer care and help patients by doing our jobs more reliably and more efficiently.”

The Durham VA Patient Safety Center of Inquiry (PSCI) successfully renewed their grant from the VA National Center for Patient Safety, with funding through Oct. 1, 2011.

The $600,000 grant will support their new project, “Designing a Safer OR to ICU Patient Handover.”

The PSCI will be building on techniques they’ve developed which utilize high fidelity medical simulation as a training tool for nurse-physician teams and physiologic and clinical monitoring of patients. Their goal is to re-engineer the OR to ICU transfer process and improve patient safety through the design and implementation of a standardized handover tool and a structured handover process.

The PSCI is led by VA anesthesiologists Jonathan Mark, M.D., Becky Schroeder, M.D., and Atilio Barbeito, M.D., and members of the Duke Human Simulation and Patient Safety Center, Jeff Taekman, M.D., Melanie Wright, Ph.D., and Noa Segall, Ph.D.

The growing multidisciplinary research group includes a cardiothoracic surgeon (Zane Atkins, M.D.), VA informatics consultant (Sally Kellum RN, MSN), quality improvement nurse (Dawn Rogers, RN), consultants from the Duke Fuqua School of Business Center for Leadership and Ethics (Sim Sitkin, Ph.D. and James Emery, Ph.D.), and technical support staff (Gene Hobbs, Becky Perfect). The PSCI will be recruiting a Program Support Manager to operate and run the VA high fidelity medical simulator and manage day-to-day administration of the Durham PSCI activities. Responsibilities includes budgetary, personnel, communication, and workload coordination duties, as well as data collection, record management, assisting with IRB/R&D compliance regulations, administering surveys, obtaining informed consent from staff, and assisting with analytical observations of direct and simulated patient care activities.

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