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Current Reviews for
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Anesthesia Patient Safety:
Is It Time for a Handoff Checklist?
Jason Lowe, PhD(c), CRNA
Assistant Program Director
Nurse Anesthesia Program
York College of Pennsylvania/WellSpan Health
York, Pennsylvania
Chuck Biddle, CRNA, PhD
Professor and Staff Anesthetist
Virginia Commonwealth University Medical Center
Richmond, Virginia
Upon completion of this lesson, the reader
should be able to:
Cite the value of the 2000 Institute of
Medicine report, To Err is Human, in
helping to define the role of anesthesia
care as a cause of in-hospital death.
Critique recent research that explores the
rate of adverse events associated with
error in high quality hospitals.
Identify high quality papers, such as the
Harvard Medical Practice Study that lists
the most common types of adverse events
that occur in the operating room.
Discuss and demonstrate the importance
of embracing a culture of safety.
Appraise the value of historical views of
error, like that of Freud, in light of more
enlightened thinking.
Interpret the 2007 Joint Commission National Safety Goal 2E in terms of how it
addresses patient care.
Explain the value and findings of
Cooper’s 1978 landmark study involving
errors associated with anesthesia care.
Illustrate the value of a checklist as it
relates to promoting a culture of safety.
List several contemporary pneumonics
associated with patient handoff checklists.
Recognize the limitations of checklists
that are frequently cited by its critics.
Current Reviews for Nurse Anesthetists designates this lesson
for 1 CE contact hour in patient safety/medical errors/risk management.
Certified Registered Nurse Anesthetists (CRNAs) are
charged with providing safe anesthesia care to
patients more than 32 million times per year. For
each patient that receives anesthesia care, safety
is a primary goal during the perioperative period.
Patient safety is so central to anesthesia care that it
is identified in the American Association of Nurse
Anesthetists (AANA) vision statement, mission
statement, core values and motto.
The National Patient Safety Foundation
defines patient safety as “the avoidance, prevention and amelioration of adverse outcomes
or injuries stemming from the processes of
health care.” The anesthesia profession is frequently regarded as an iconic leader in patient
safety. The Institute of Medicine report, To Err is
Human, stated “Anesthesiology has, over time, successfully reduced anesthesia mortality rates from
two deaths per 10,000 anesthetics administered to
one death per 200,000-300,000 anesthetics administered in low risk patients.” While this value has
been criticized as being poorly grounded in strong
science, the improvement is noteworthy.
Even though anesthesia is much safer than ever
before, patients are still harmed during the perioperative course. Despite the dedication of CRNAs
to patient safety, mistakes still occur. Safe medication administration continues to be a problem as
Curr Rev Nurs Anesth 36(18):217-228, 2014
medication errors still occur at an alarming rate. We
know that wrong-patient, wrong-procedure, wrongsite scenarios occur in the perioperative period
despite efforts to prevent this unthinkable error.
Consider the following scenario chronicled recently in
the New England Journal of Medicine.1
You completed an excellent anesthetic only to
discover that the carpal tunnel release that was performed was scheduled to be a trigger finger release.
The patient is understandably upset at the surgeon,
the surgical team and the health care facility.
Although no direct harm was caused to the patient,
the results of this error are devastating. The patient
loses trust in the health care system and is left to
cope with physical and emotional wounds. A lawsuit
ensues with a wide range of negative ramifications.
Despite claims of great advances in anesthesia patient safety, many errors, sometimes with catastrophic outcomes, still
occur at a vexing rate.
Events such as this are often headline news
stories and the public is shocked that such errors
could occur. How could a team of highly trained
medical professionals allow a patient to be harmed
by human error? Questions are asked such as: is it
true that we are safer driving a car than being in a
hospital bed? Doesn’t the doctor pay attention?
Where were the nurses and others in the room?
Could this happen to me during surgery? These are
questions that you may hear or questions that play
out on the evening news.
You take pride in your job and believe that this
will never happen to you. The reality however, is
that errors occur every day in the health care delivery system despite well-intentioned and highly
trained health care professionals. The purpose of
this lesson is to identify the problem, review handoffs
in anesthesia and consider solutions to communication failures.
Defining the Problem
“It is impossible for the nation to achieve the greatest
value possible from the billions of dollars spent on
medical care if the care contains errors” (Kohn et al,
Causing harm is probably one of our greatest
worries when providing patient care. Devastating
human errors occur every day in our hospitals and
surgery centers. We are aware that preventable
errors occur too frequently under our watch. Errors
range from the seemingly benign, such as a delayed
antibiotic administration, to the unfathomable, such
as the administration of a lethal dose of medication.
In 1999, The Institute of Medicine estimated
that at least 44,000 and as many as 98,000
patients die in hospitals in the U.S. each year,
Current Reviews for Nurse Anesthetists®
with upwards of a million ‘injuries’ from preventable medical errors.2 These staggering numbers place medical error as a leading cause of death.
Even using the lower estimate, deaths related to
medical error continue to exceed motor vehicle
accidents (43,667), breast cancer (41,491) or AIDS
(12,543) related deaths. Medical errors are costly in
terms of lives lost, as well as disability, health care
expenditure, and lost income. The total national cost
of adverse events in 1999 was estimated to be 37.6
billion dollars (nearly 4% of national health care
expenditures for 1996) with 17 billion attributable to
preventable adverse events. Now over a decade
later, that cost is likely even higher.
It has been shown that up to 30% of patients are
victim to one or more medical errors during their
hospitalization.3 Another study concluded that
45.8% of patients had an adverse event during hospitalization with 17.7% of these experiencing disability or death. For patients who are hospitalized,
the risk of an adverse event increases about 6% for
each day of hospitalization.4 Recent systematic
research reveals that adverse events occur in
one-third of admissions in high quality hospitals and are frequently the result of human
The Harvard Medical Practice Study, 6 which the
IOM report was based on, demonstrated that nearly
half of adverse events were related to the operating
room. The most common types of adverse events
were drug errors (19%), iatrogenic infections (14%)
and technical complications (13%). Recent Joint
Commission data show that of all reported sentinel
events, wrong-site surgery (13.7%), operation/postoperative complication (10.4%) and procedure-related
medication error (6.0%) commonly occurred.7
What is perhaps most sobering is that since
the 1999 IOM report, “To Err Is Human”, there
is little data demonstrating that we are any
safer. Although there is unmistakable progress in
patient safety research and awareness of safety
issues, we still lack adequate reporting of errors and
data that shows we are causing less harm. The 2008
National Quality Healthcare Report claimed that
patient safety was getting worse, not better. The
report stated that health care quality has failed to
improve at an acceptable pace.8 The Safe Patient
Project 9 shows that preventable medical harm continues to account for over 100,000 patient deaths per
year, or over one million deaths in the past 10 years
since the IOM report was released.
Why Humans Fail
If we are going to provide safe patient care (free from
accidental injury) and reduce the number of errors,
then we have to learn how humans fail. Error is
defined as the failure of a planned action to be completed as intended or the use of a wrong plan to
achieve an aim. Sigmund Freud was an early error
theorist and believed error to be the result of an
unconscious drive. He concluded that those who
committed error were deficient and error prone. His
error theory places the blame solely on the “error
prone” person, noting that the only way to improve
safety is through remediation or removing the error
prone person from providing care.
This outdated theory, also termed the “bad apple
theory” sees humans as the sole cause of trouble.
This view does not account for the complexities or
system flaws that lead to many errors and it does not
account for the limits of human memory. The major
flaw of this error theory is its assumption that people
can choose between making errors and not making
them. If simply a matter of choice, fewer errors
would occur in health care, given the highly trained
and generally benevolent attributes of health care
Reports such as that of the Institute of
Medicine’s, To Err is Human, have focused
much needed attention on the genesis and
remedy of errors in healthcare.
A revisionist view sees human error as a symptom of deeper trouble; not that humans are solely the
cause for failure, but that systems are often inherently unsafe. Systems, including the health care
system, exist to make money, render service, and
provide products; but not necessarily to be safe.
Hospitals, and the OR environment in particular, are
considered to be inherently dangerous. The OR environment is as complex as nearly any system on
Earth. Nurse anesthetists manage highly technical
anesthesia gas machines, multiple and dangerous
medications, computerized charting, often bewildering infusion pumps, a dizzying array of electronic
monitors and alarm systems all while caring for
patients with a range of pathophysiological challenges who are undergoing surgical assault.
Reason10 describes two types of errors, active
errors and latent errors. Active errors have effects
that are felt almost instantaneously. Latent errors/
conditions lie dormant within a system for a length
of time and their consequences become evident only
when other factors combine to cause a breakdown in
the system. Growing evidence shows that discovering and neutralizing these latent conditions will have
a much greater effect on system safety than efforts to
minimize active errors.
Examples of latent conditions include: 1) poor
team communication which prevents the team
from conducting a successful preoperative briefing
and allows for wrong-site surgery or 2) production
pressure that causes the anesthetist to skip steps
which lead to a medication error or an inadequate
anesthesia gas machine check. It is important to
remember that patient safety does not improve by
blaming individuals for errors (see Culture of Safety
below). Instead, it is of greater benefit to identify the
latent conditions that allowed the error to occur and
remove them.
Current human error theory recognizes the complexity in which people work and the limits of human
memory. The goal then becomes designing
systems that minimize the human factor and
prevent latent conditions from compromising
patient safety. System improvements include automated anesthesia gas machine checks, standardization of medication dosages and “time-outs” before the
start of procedures.
Causes of Errors
Common culprits that are blamed for error include
inadequate staffing, lack of competency or poor
training. Increasingly, we are seeing that communication failure is identified as a primary factor in
error-related patient harm (Figure 1). Joint Commission data reveals that communication failure is a
primary root cause of sentinel events.7 Cooper,11 in
his now classic study, identified poor communication
as one of the most common associated factors in
anesthesia mishaps. Various reasons for communication breakdown have been identified. The reduction in resident physician hours may be exerting a
downstream consequence: decrease in work hours
increased the number of times a patient’s care is
transferred, increasing the risk of communication
Communication Failures
and the Handoff Process
“The problem with communication….is the illusion
that it has been accomplished.” – George Bernard
Providing care to patients has become increasingly complex. One person cannot be expected to
provide the entirety of care for a patient on his or her
own. Therefore, patient care generally involves multiple providers and a number of different specialty
services within the system. Because providers
often work in shifts, patients see multiple providers throughout their stay due to shift
changes and breaks. Each time patient care is
transferred a “handoff” occurs. Patient handoffs are recognized as a vulnerable point in the process of patient care. During the handoff, valuable
information can be omitted or misinterpreted leaving the patient at risk for errors. The more frequently that handoffs occur, the greater the risk of
communication failure and patient care errors.12
The Joint Commission recognized the inherent
risks of patient handoffs and in 2007 created
national safety goal 2E, stating that a standardized
approach to handoff communication should be implemented (Figure 2). Ideally, a patient “handoff” is
defined as a two-way process of the explicit comCurr Rev Nurs Anesth 36(18):217-228, 2014
Table 1
Common Examples of Handoff Mnenomics in Current Use
Stands for
Target group(s)
Hospital room/ward
Allergy/adverse reactions
Do not resuscitate?
Ongoing problem(s)
Facts about care
Follow up on….
Scenarios (possible)
Physicians / nurses
Demographics (patient)
Mechanism of injury
Injuries sustained
Signs and symptoms
Treatment provided
Ambulance and
emergency department
Patient / Problem(s)
Assessment / Action
Continuing / Changes
Physicians / nurses,
technicians and
ancilliary staff
Originally intended for
perioperative nurses
Subjective information
Objective information
department and
neuroscience nurses
Plan of care
Purpose / goals
Perioperative nurses
time of “great risk to the patient.””13 Researchgrounded checklists may have particular value in
facilitating the transfer of important information as
they create what might be termed “forcing functions”
by cueing the transfer of vital patient data.
The Value of a Checklist
Good communication is essential for safe and effective patient care. Instead of relying exclusively on
memory, checklists have been proposed to maximize
the information transfer during the handoff. We use
checklists frequently to help us manage our daily
routines. These checklists include shopping lists,
Current Reviews for Nurse Anesthetists®
to-do lists, recipes and reminders that help us to
remember important things. We also have many
checklists that help us in anesthesia including:
• Anesthesia gas machine checklist
• Surgical checklist / time-outs
• Difficult airway algorithm
• Malignant hyperthermia checklist.
Checklists serve two purposes: 1) a memory aid,
eases complexity, orders steps in the most logical
manner and 2) a forcing function for communication
of key issues.
Checklists can also create problems if they are
not attitudinally embraced within the culture of the
organization in which they are used. We believe that
checklists, unless associated with attitudinal change
by the organization (and its users) are not likely to
have success. That is, technical solutions rarely
solve adaptive problems. If used improperly or if
poorly designed, checklists:
• Can be a distraction
• May be viewed as interfering
• May be viewed as eroding autonomy
• May impede swift decision making when it is
Culture of Safety
Nurse anesthetists are patient safety advocates and
work to provide for safe patient care during the
perioperative period. Frequently, we look to the
aviation industry to provide us with examples of
ways to improve safety. Aviation responded to their
safety crisis in the 1970s by introducing Crew
Resource Management (CRM). There were several
high profile accidents, including the Tenerife Island
accident in 1977, that were blamed on human error.
The Tenerife crash was the deadliest accident in
aviation history. Two passenger jumbo jets collided
resulting in 583 deaths. Latent conditions included
time pressure, a language barrier and communication failures. Most notable was the poor communication that occurred in the cockpit between the
captain and his crew.
A functional checklist must prompt information transfer efficiently and concisely
and must be embraced as part of the culture of safety of the institution or it will
Given the complexity of what we do, we need
teams to help us achieve the safest outcomes. We
must design teams that function to identify active
and latent errors. This teamwork consists of surgeons, anesthetists and OR staff that are patient
centered and view patient safety as their first priority.
The components of a culture of safety include:
• Commitment to safety on an organizational level
• Resources and incentives to allow commitment
to safety
• Safety is first priority, ahead of other system
• Communication is paramount
• Openness about errors and problems
• Focus on improving system performance and not
individual blame
• A culture of safety is endorsed by many patient
safety groups.
The OR is a unique cultural environment with
system factors associated with production pressure,
cost containment and hierarchies. The team minimally consists of an anesthesia provider, surgeon,
circulating nurse and scrub technician. Each of
these team members is trained in their separate
disciplines to perform specific duties, yet not always
with a team mentality. In a complex environment,
teams rely heavily on interdependence and team
coordination, yet these skill are often lacking in the
OR where communication among team members may
be poor. Communication is a core teamwork skill.
Poor communication among team members and the
failure to adequately communicate are prominent
patient safety issues. Improved communication is
essential to reducing errors as the root cause for
many errors is communication breakdown.
A culture of safety is common in other high-risk
areas such as the airline industry and nuclear power
plants. These industries recognize human limits and
see error recognition as an opportunity to decrease
risk. A culture of safety must be an integrated
approach where safety is reinforced with team training. Team training should be interdisciplinary and
address team communication and conflict management.
Checklists and Culture of Safety
When properly designed and introduced within a
supportive culture and grounded in operational
reality, a quality checklist:
• Provides a sequential set of steps
• Allows for cross checking from other team members
• Enhances a team concept by keeping members in
the loop
• Enhances coordination and performance during
stressful situations.
The Future
High quality communication of information among
health care providers is vital to ensuring patient
safety. Handoff information should be presented in
a standardized format that ensures that essential
information is conveyed. This standardized format
will decrease omissions and commissions that lead to
errors in care. The use of a checklist cannot be a
mandate that creates the thought of “just another
form to complete.” Anesthetists must possess the
discipline to put patient safety ahead of all other
competing interests. Embracing a culture of safety
allows for patient safety to be elevated to its rightful
spot as our top priority.
Anesthetists are highly trained providers who
possess greater knowledge than ever before. We
have also been provided with tremendous technology
designed to make our jobs easier and to provide safe
and effective care to even the most challenging of
patients. Despite this knowledge and technology,
mistakes still occur too often. In our complex en-
Curr Rev Nurs Anesth 36(18):217-228, 2014
vironment with significant competing sensory inputs,
we can become pressured and distracted. The value
of a checklist serves as a “forcing function” to prompt
essential communication and information transfer
during critical times and to avoid over-reliance solely
on memory.
Nurse anesthetists are dedicated to patient
safety. We are uniquely positioned to advocate for
safe patient care practices. It is our responsibility to
put patient security first and embrace what has come
to be known as a culture of safety. Look for ways to
improve your handoff communications through a
standardized approach using a checklist.
Chuck Biddle, CRNA, PhD, Professor and Staff Anesthetist, Virginia Commonwealth University Medical Center, Richmond, Virginia. [email protected]
Jason Lowe, PhD(c), CRNA, Assistant Program Director, Nurse Anesthesia Program, York College of Pennsylvania/WellSpan Health, York, Pennsylvania. [email protected]
Ring DC, Herndon JH, Meyer GS: Case 34-2010-A
65 year old woman with an incorrect operation on
the left hand. N Engl J Med 363:1950-1957, 2010.
Kohn LT, Corrigan JM, Donaldson MS: To Err is
Human: Building a Safer Health System. Institute
of Medicine Committee on Quality of Health Care
in America. National Academy Press. Washington
DC, 2000.
Schimpff SC. Improving operating room and perioperative safety: background and specific recom-
Current Reviews for Nurse Anesthetists®
mendations. Surgical Innovation 14(2):127-135,
Andrews LB, Stocking C, Krizek T, Gottlieb L,
Krizek C, Vargish T, Siegler M: An alternative
strategy for studying adverse events in medical
care. Lancet 349:309-313, 1997.
Classen DC, Resar R, Griffin F, et al.: Global
trigger tool shows that adverse events in hospitals
may be 10 times greater than previously measured. Health Affairs 30:581-589, 2011.
Brennen TA, Leape LL, Laird NM, et al.: Incidence of adverse events and negligence in hospitalized patients: results of the Harvard medical
practice study 1. N Engl J Med 324(6):370-376,
Sentinel Event Statistics 2010. The Joint Commission. www.joint
quarterly/. Accessed October 17, 2011.
National Quality Healthcare Report 2008. AHRQ.
htm. Accessed October 8, 2011.
To Err is Human – To Delay is Deadly.
Summary. Accessed October 8, 2011.
Reason JT: Human Error. Cambridge University
Press, Cambridge, England, 1990.
Cooper J: Preventable anesthesia mishaps: A study
of human factors. Anesthesiology 49:399-406, 1978.
Solet DJ, Morvell M, Rutan GH, Frankel RM:
Lost in translation: challenges and opportunities
in physician-to-physician communication during
patient handoffs. Academic Medicine 80(12):10941099, 2005.
Clancy C: The importance of simulation: preventing hand-off mistakes. AORN 88:625-627, 2008.
Tips for your Clinical Practice: Key Points
Human error is inevitable, especially under conditions of complexity and production pressure;
cognitive function erodes quickly when stress and fatigue are factored in.
A good checklist consists of action items systematically arranged to ensure that well defined,
essential information is both considered and efficiently managed.
Regardless of the nature of the checklist, its principal purpose is to create a tool to reduce errors,
ensure best practice adherence, and optimize patient outcome.
While checklists are widely used, few have been systematically studied in terms of improving patient
Checklists have strongly influenced the domain of critical care (ICU, surgery, etc.) as they are
particularly relevant due to the inherent complexity of the domain.
Chuck Biddle, CRNA, PhD
Professor and Staff Anesthetist
Virginia Commonwealth University Medical Center
Richmond, Virginia
The author / faculty has indicated that there is no relevant financial interest or relationship w ith any com m ercial interest.
The author / faculty has indicated that, as appropriate, he/she has disclosed that a product is not labeled for the use under discussion, or is still
under investigation.
As a m atter of p olicy, F M C E P d oes n ot h ave any relevant finan cial interest o r relationship w ith any com m ercial interest. In add ition, all m em bers
of the staff, G overning B oard, Editorial B oard and C M E C om m ittee w ho m ay have a role in planning this activity have indicated that there is no
relevant financial interest or relationship w ith any com m ercial interest.
C urrent R eview s is intended to provide its subscribers with inform ation that is relevant to anesthesia providers. However, the inform ation published
herein reflects the opinions of its authors. Anesthesia practitioners m ust utilize their know ledge, training and experience in their clinical practice
of anesthesiology. No single publication should be relied upon as the proper w ay to care for patients.
C urrent Review s for N urse A nesthetists (C R N A) is d esigned to m eet the standards and criteria o f the A m erican A ssociation of N urse Anesthetists
(AAN A) for the prior-approved continuing m edical education activity, Provider-D irected Independent Study, also know n as hom e study. CR N A is an
app roved program provider.
C R N A has designated the lessons which m eet specific content areas such as pharm acology, H IV /AID S , etc. How ever, only the Board of N ursing
of an individual State is the final authority in the determ ination of w hether or not these lessons m eet the State’s licensure requirem ents.
Curr Rev Nurs Anesth 36(18):217-228, 2014
In accordance with AANA directives, you must get 80% of the answers correct
to receive one credit for each lesson, and “if there is a failure, there is no retaking”.
The 2000 Institute of Medicine report, To Err is
Human, suggested that the rate of death due to
anesthesia in low risk patients was:
G A. 1 in 1,000.
G B. 1 in 10,000.
G C. 2 in 10,000.
G D. 1 in 100,000.
G E. 1 in 200,000-300,000.
Recent research suggests that adverse events
associated with error in high quality hospitals occur
in what percentage of hospitalized patients:
G A. ~1%.
G B. ~2%.
G C. ~10%.
G D. ~15%.
G E. ~30%.
The 1991 Harvard Medical Practice Study noted that
common types of adverse events in the operating
room were due to:
G A. Drug errors.
G B. Iatrogenic infections.
G C. Technical complications.
G D. Communication failures.
G E. All of the above were common
Freud, as an early error theorist, placed “blame for
error” primarily upon:
G A. The industrial or workplace “system”.
G B. The U.S. educational system.
G C. The U.S. Federal Government.
G D. The error prone person.
G E. None of the above.
The 2007 Joint Commission National Safety Goal 2E
addressed the following aspect of patient care:
G A. Handoff communication.
G B. Medication reconciliation.
G C. Human factors/technology interface.
G D. Blood transfusion therapy.
G E. Hand hygiene.
The TRUE statement regarding Cooper’s 1978 landmark study involving error associated with anesthesia care is:
G A. There were no errors observed in his study.
G B. The relief anesthesia provider often discovered
errors unknown to the current provider.
G C. The importance of relief breaks for anesthesia
providers was demonstrated.
G D. B and C are true.
G E. None of the above are true.
The following is NOT important to a culture of
G A. Commitment to safety on an organizational level.
G B. Resources and incentives to allow commitment
to safety.
G C. Safety is the first priority ahead of other system
G D. Openness about errors and problems.
G E. Immediate firing of any individual who commits
an error.
The value of a checklist is related to it being:
G A. An aid to memory.
G B. Embraced by the culture within which it is used.
G C. A mechanism to force communication of important information.
G D. A standardized approach to information transfer.
G E. All of the above.
Many pneumonics exist for checklists, as an
example SBAR stands for:
G A. Situation, background, assessment, recommendations.
G B. Staffing, baseline vitals, cardiac arrest risk, recommendations.
G C. Situation, basic labs, anticipated care, risk of
G D. Saturation (of hemoglobin), baseline consciousness, airway, reflexes intact.
G E. Sensorium, baseline vitals, airway, recommendations.
10. Critics of checklists, frequently cite the following as
G A. They can be distracting.
G B. They may be viewed as interfering.
G C. May be viewed as eroding autonomy.
G D. May impede swift decision making when it is
G E. All of the above.

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