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Tony Mira, Chairman and Chief Executive Officer of MiraMed

Inside information for anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) on the most current best practices during changing times.

Adding Focus and Structure to Anesthesia Patient Handoffs

Patient handoffs are a significant source of errors in intraoperative and perioperative settings. Efforts to reduce these errors often succeed at first, but do not result in behavior change that lasts. A highly structured six-stage patient handoff implementation strategy developed at Midland Memorial Hospital in Texas has reduced handoff errors by half and generated improvements and behavior changes that have been sustained since the strategy's introduction three years ago.

Medical errors rank as the third leading cause of death in the United States, with communication errors during patient handoffs causing an estimated 80 percent of serious errors. According to a study of hospitals and medical practices released in 2016, communication failures were at least partly responsible for 30 percent of all malpractice claims. These communication errors led to 1,744 deaths and $1.7 billion in malpractice claims over five years. Nowhere is the thorough and accurate communication needed to prevent these handoff errors more crucial than among the surgeons, anesthesiologists, intensivists, nurse anesthetists, PACU nurses and other caregivers in the intraoperative and perioperative space. 

As anesthesia providers continue to assume expanded responsibilities for patient care through the development of perioperative surgical homes in their facilities, their ability to address problems related to patient handoffs is likely to become an even more central aspect of their work. 

Implementing handoff improvements and sustaining behavior changes for the long term remain a challenge for providers, despite the introduction of a standard for patient handoffs by the Joint Commission (TJC) in 2010, the creation of a comprehensive Transitions of Care (ToC) portal, and the development of various tools and techniques, including the Association for Healthcare Research and Quality's TeamSTEPPS® program and mnemonics, such as ISBAR, I PUT PATIENTS FIRST and I-PASS

Handoff-related problems are only amplified by the frequency of handoffs, according to a 2017 TJC sentinel event alert. More than four thousand handoffs can occur in a typical teaching hospital in a day. Often performed too informally, these transitions demand a more focused and structured approach to ensure safety and continuity of care, TJC argues. 

The perioperative team at Midland Memorial Hospital (MMH) in Texas developed a systematic handoff protocol using a six-stage implementation strategy that appears to provide the focus and structure for significant behavior change that TJC says healthcare organizations need. In 2012, the hospital implemented TeamSTEPPS®, but early success with the curriculum proved fleeting. The enhanced protocol has reduced handoff errors by more than half and led to improvements and behavior changes that have lasted since its implementation more than three years ago. 

The percentage of handoffs with missing or inaccurate information has stayed consistently under 10 percent, which translates into each PACU nurse receiving only one deficient handoff per week. The PACU nurses report that when handoff problems do occur they are generally minor, and the structured approach helps them identify omissions earlier. 

Data show a 40 percent faster improvement in Aldrete scores in the PACU and a two percent reduction in hospital length of stay, which translates into a yearly cost savings of $1 million for this hospital. 

"The core idea was that managers and staff would systematically work together to change their behaviors and work processes, rather than working in a limited and idiosyncratic fashion," report Margaret M. Luciano, PhD, of the WP Carey School of Business at Arizona State University in Tempe and Bob Dent, DNP, MBA, RN, FACHE, FAAN, chief operating and chief nursing officer at MMH, in a recent article in Harvard Business Review

The hospital's six-stage implementation strategy focuses on creating lasting behavior change and consists of the following groups of tasks: 

Preparing: collecting baseline data on handoff quality indicators; developing a quality improvement plan; organizing items for a new protocol and checklist. 

Launching: training providers on the new protocol and checklist in one-hour training sessions, supplemented by individualized coaching. 

Adjusting: surveying providers for their input on how to improve and fine-tune the protocol, to increase a sense of ownership and commitment to the process. For example, handoffs were taking longer as providers learned the new protocol, which led to a perception that the circulating nurses were not working efficiently. Managers immediately addressed this misperception in an inservice and arranged for additional staff to help clean the ORs. After a month of adjusting, a follow-up survey revealed satisfaction with the improvements. 

Boosting: helping providers maintain and enhance their effectiveness, with an emphasis on the behavior changes needed to make the transition, notably, remaining engaged and at the bedside throughout the handoff. This required a shift in mindset from a focus on individual roles to a focus on working with others and providing backup across units (e.g., OR nurses helping PACU nurses). To help providers make the shift, coaching emphasized the importance of the crosscheck and included concrete examples. 

Formalizing: taking the new protocol through the administrative steps required to make it a formal hospital policy and a requirement, including evaluation of the protocol's impact on patient recovery. 

Refreshing: training new perioperative staff and providing yearly refresher training to current staff. 

Approaching the changes and improvements as a process rather than an event; involving both management and staff; and systematic evaluation during all six stages of implementation were key to the initiative's success, according to the authors. They believe the same six-stage approach could be used in other aspects of healthcare process improvement. 

Has the perioperative team at your institution had success with any strategies and techniques for improving patient handoffs? What has worked for you? Please share your experiences and ideas at

With best wishes, 

Tony Mira 

President and CEO