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October 13, 2014
10:00 AM - 12:00 PM
Room Hall B1-Area E
Toward a Safer Handoff: Preventable Barriers to High Quality Postoperative Communication
Erin W. Pukenas, M.D., Irwin Gratz, D.O., Elaine Allen, Ph.D., Amanda R. Burden, M.D., Taral Patel, M.D., Brittany Scarpato, B.S., Erin McIntosh, B.S., Edward R. Deal, D.O.
Cooper Medical School of Rowan University, Camden, New Jersey, United States

Poor postoperative handoff communication is associated with significant medical error (1). Handoffs with distractions correlate with omission of critical patient data during information exchange (2). Previously identified distractors within the hospital setting include noise, irrelevant communication, and external staff (2). Ambulatory surgery centers aim for efficient operating room throughput and high quality patient care with a target operating room turnover time of 7-10 minutes (3).The authors sought to characterize communication barriers within a busy, high-volume ambulatory surgery center (ASC) and the effect of distractions on handoff duration and error.


Eighty handoffs in an ASC were audio-recorded over a 6-week period. Satisfaction surveys were completed by the information senders and receivers for every handoff. Trained observers rated the quality of each handoff performance and documented distractions and secondary task activity during handoff communication. Each handoff was timed for completion of patient care and information exchange.


Forty percent of handoffs were associated with communication distractions (n=28). Information exchange times were significantly longer in the presence of distractions (1.5 minutes versus 2.3 minutes, p<0.001). Handoff satisfaction scores, as rated by the sender, were significantly lower in handoffs with distractions (p<0.05). Handoffs with communication distractors were also rated lower in overall quality (p<0.05) by trained observers and were associated with a greater number of errors (defined as transfer of incorrect information). Handoff communication distractors, by category, are shown in the accompanying graph.


As case volume shifts from the inpatient to outpatient arenas, the ambulatory handoff may represent an opportunity to improve upon patient safety. Distracted handoff communication may result in longer time to transition of patient care. This may have important implications in busy settings with high case turnover. In this study, nearly 50% of distractions during postoperative handoffs may have been preventable. Additionally, distracted communication was shown to be associated with a higher incidence of transference of incorrect information. Consideration should be given to identifying and minimizing distractions within postoperative care environments. As organizations continue lean management strategies, staff resource constraints and physical environments of ambulatory postanesthesia care units may deserve special attention.


1. The Joint Commission Center for Transforming Healthcare.

2. Nagpal K, et al. Evaluation of postoperative handover using a tool to assess information transfer and teamwork. Ann Surg 2011;253:831-837.

3. Miller L.
Figure 1

Copyright © 2014 American Society of Anesthesiologists