Standardizing the Post-Operative Handoff of Patient Care Between Providers in the Neonatal Intensive Care Unit

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Huggins, Molly
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Purpose: The purpose of this project is to develop and implement a standardized post-operative hand-off process in a level IV NICU to facilitate provider communication during critical transitions and improve patient safety.|Background: The total number of neonatal procedures nationwide averages over 200,000 per year. Communication during provider handoff is essential to patient safety during the critical transition period of the post-op NICU patient. Communication failures during the patient handoff period account for 59-82% of sentinel events. This is a critical transition period was recognized by the Vermont Oxford Network as a main aim for quality improvement in 20222 and continues to be recognized by the Joint Commission as a directive for quality improvement.|Design: Plan, Do, Study, Act (PDSA) cycle was used as the conceptual framework for this project.|Methods: Retrospective data collection of Safety Learning Reports (SLRs) surrounding the post-operative care of surgical patients in the NICU were obtained from an 18-month pre-implementation period. A standardized post-op handoff report between providers was developed using the essential elements of provider handoff report identified by the Vermont Oxford Network2. The handoff report tool was implemented in the 44-bed level IV NICU at Children’s Minnesota. Post-implementation data collection occurred over a 10-week period. NICU nurses and anesthesiologists present at handoff completed an audit tool for compliance measurement.|Results/Conclusion: Standardized patient handoff between providers at the bedside is an effective strategy to identify and prevent medical errors, reducing the potential for harm to the patient. Twenty-nine SLRs occurred surrounding post-op care of the NICU patient prior to the implementation of standardized provider handoff. Reported errors included incorrect patient diet/NPO status, IV rates, medication, level of activity or bedrest, and surgical site care instructions. Twenty-one patients underwent a surgical procedure during post-implementation period. There were 0 SLRs filed during this period, and 5 errors identified during bedside handoff that prevented patient harm including: endotracheal tube placement (ETT) at incorrect measurement (1); incorrect size of ETT; incorrect IV fluid rate (1); undocumented or incorrect drain/indwelling device (2).
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