Martins Nara Regina Spall, Martinez Edson Zangiacomi, Simões Cláudia Marquez, Barach Paul Randall, Carmona Maria José Carvalho
Faculdade de Medicina, Universidade de São Paulo (USP), Av. Dr. Arnaldo, 455 - Sala 4107, São Paulo, São Paulo 01246-903, Brazil.
Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), Avenida Bandeirantes, 3900 Bairro Monte Alegre, Ribeirão Preto, São Paulo 14049-900, Brazil.
Int J Qual Health Care. 2025 Jan 17;37(1). doi: 10.1093/intqhc/mzae114.
Patients continue to suffer from preventable harm and uneven quality outcomes. Reliable clinical outcomes depend on the quality of robust administrative systems and reliable support processes. Critically ill patient handoffs from the operating room (OR) to the intensive care unit (ICU) are known to be high-risk events. We describe a novel perspective on how risk factors associated with the process of patient handoff communication between the OR and the ICU can lead to flawed communication, degraded team awareness, medical errors, and increased patient harm. Data were collected from two semi-structured focus groups using a five-step risk management approach at a tertiary hospital in São Paulo, Brazil. We conducted a failure modes and effects analysis (FMEA) with multidisciplinary healthcare providers consisting of attending physicians, anesthesiologists, nurses, and physiotherapists involved in patient handoffs. We analyzed the results using a similitude analysis to evaluate the effectiveness of implementing this novel risk management approach. We identified the handoffs risks associated with patients, staff, institution, and potential financial risks. The FMEA identified 12 process failures and 36 causes that generated 12 consequences and pointed to robust needed preventive measures to mitigate handoff risks. The clinical teams reported that this approach allowed them to see the process more completely as a whole not only in their narrow silos, thus understanding the enablers and difficulties of the other team members and how this understanding can shed light on their mental models, actions, and the process reliability. Teams identified key steps in the OR to ICU handoff process that are prone to the highest hazards to patients, the hospital, and staff, and are currently targeted for process improvement. Evidence-driven recommendations intended for reducing the risks associated with patient handoffs are presented. Implementing a dynamic risk management, interdisciplinary approach was used to redesign the OR to ICU patient handoff approach around the patient's and clinician's needs. The risk management program helped healthcare providers identify handoff steps, highlighting risky handoff process failures, making it possible to identify actionable failures, consequences, and define preventative action plans for mitigating the risks to improve the quality and safety of patient handoffs.
患者仍在遭受可预防的伤害以及质量参差不齐的后果。可靠的临床结果取决于强大的管理系统质量和可靠的支持流程。已知从手术室（OR）到重症监护病房（ICU）的重症患者交接是高风险事件。我们描述了一种新的视角，即与手术室和重症监护病房之间患者交接沟通流程相关的风险因素如何导致沟通失误、团队意识下降、医疗差错以及患者伤害增加。数据是在巴西圣保罗的一家三级医院，通过五步风险管理方法从两个半结构化焦点小组收集的。我们与参与患者交接的包括主治医生、麻醉师、护士和物理治疗师在内的多学科医疗服务提供者进行了失效模式与效应分析（FMEA）。我们使用相似性分析来评估实施这种新型风险管理方法的有效性，以此分析结果。我们确定了与患者、工作人员、机构相关的交接风险以及潜在的财务风险。FMEA识别出12个流程故障和36个原因，这些原因产生了12个后果，并指出了为减轻交接风险所需的有力预防措施。临床团队报告称，这种方法使他们不仅能在各自狭隘的领域内，而是更全面地将整个流程视为一个整体，从而理解其他团队成员的促成因素和困难，以及这种理解如何能阐明他们的思维模式、行动和流程可靠性。团队确定了手术室到重症监护病房交接流程中对患者、医院和工作人员危害最大且目前针对流程改进的关键步骤。提出了旨在降低与患者交接相关风险的循证建议。围绕患者和临床医生的需求，采用动态风险管理的跨学科方法重新设计了从手术室到重症监护病房的患者交接方法。风险管理计划帮助医疗服务提供者识别交接步骤，突出有风险的交接流程故障，从而有可能识别可采取行动的故障、后果，并定义预防行动计划以减轻风险，进而提高患者交接的质量和安全性。
