• Lisa M McElroy, Kathryn R Macapagal, Kelly M Collins, Michael M Abecassis, Jane L Holl, Daniela P Ladner, and Elisa J Gordon.
• Center for Healthcare Studies and Center for Education in Health Sciences, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Northwestern University Transplant Outcomes Research Collaborative, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. Electronic address: lisa.mcelroy@northwestern.edu.
• Am. J. Surg. 2015 Oct 1;210(4):629-35.

BackgroundOperating room (OR) to the intensive care unit (ICU) handoffs are known sources of medical error, yet little is known about the relationship between process failures and patient harm.MethodsInterviews were conducted with clinicians involved in the OR-to-ICU handoff to characterize the relationship between handoff process failures and patient harm. Qualitative analysis was used to inductively identify key themes.ResultsA total of 38 interviews were conducted. Dominant themes included early communication from the OR to the ICU, team member participation in the handoff, and relationships between clinicians; clinician perspectives varied depending substantially on role within the team.ConclusionsThe findings suggest that ambiguous roles and conflicting expectations of team members during the OR-to-ICU handoff can increase risk of patient harm. Future studies should investigate early postoperative ICU care as outcome markers of handoff quality and the effect of interprofessional education on clinician adherence to interventions.Copyright © 2015 Elsevier Inc. All rights reserved.

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