Deconstructing Anesthesia Handoffs During Simulated Intraoperative Anesthesia Care

Anesthesia patient handoffs are a vulnerable time for patient care and handoffs occur frequently during anesthesia care. Communication failures contribute to patient harm during anesthesia patient handoffs. The Joint Commission has recognized the potential for communication failure during patient handoffs and has recommended processes to improve handoff safety. Handoffs are made more difficult by latent conditions such as time constraints, pressure and distractions, which often result in incomplete or inaccurate handoff reports. This nonexperimental, correlation study identified the latent conditions that occur during the handoff process and their relationship to the quality of the handoff. This research shows an inverse relationship between latent conditions and anesthesia patient handoff scores. The number of latent conditions and the types of latent conditions affected handoff scores. Handoffs that were not interactive or handoffs with unsafe timing predictably resulted in poor handoff communication. Clinicians must acknowledge that handoffs are a high-risk event that can result in patient harm. Clear and effective communication is key to safe, quality care and this includes being aware of and minimizing the impact of latent conditions during the anesthesia patient handoff.