Anesthesia Handoff: A Root Cause Analysis Based on a Near-Miss Scenario

摘要

The Joint Commission on Accreditation of Hospital Organization (JCAHO) has handoff requirements to create the safe and effective transfer of patient information between providers. Multiple studies have investigated standardized nurse-to-nurse handoffs and nurse-to-physician handoffs. However, very few studies have examined handoff communication between anesthesia providers. A near-miss scenario during a sitting craniotomy procedure is reviewed, and a root cause analysis conducted to demonstrate the importance of communication and how a standardized anesthesia handoff tool can facilitate patient safety.