Purpose: To identify failures in the handoff from the OR to the intensive care unit (ICU) of living donor liver transplant (LDLT) that lead to medical errors and preventable complications. Handoffs are known to be particularly vulnerable process of care, where medical errors occur more frequently. Therefore, we performed a proactive, systematic assessment of the handoff at four LDLT centers.

Methods: The assessment included 40 medical record reviews (MRR), 6 video observation (OBS) at 3 centers and 2 in-person observations at a forth center. Web-based debriefings (debrief) for 74 LDLTs were collected. Data were integrated into tables for failure modes and effects analysis (FMEA), which were performed at each site. Failures were ranked by criticality based on frequency of occurrence and severity of consequence.

Results: Fragmented team member participation, inaccurate and incomplete information transfer were the top handoff-specific failures on MRR and OBS. Findings were intra- and inter-site reliable. In the FMEA 36 separate steps were identified for the handoff from the OR to the ICU. The data from the MRR, web-based debriefings and observation in conjunction with the FMEA showed that the most critical vulnerabilities in the handoffs were medication administration and communication between the surgical and ICU teams.

Conclusion: Incomplete team participation and failure in communication (information transfer) are the primary failures in handoffs of LDLTs from the OR to the ICU. Standardization of this recurrent and brief process might improve patient care, LDLT outcomes, and clinician satisfaction.

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