Improved patient safety with a simplified operating room to pediatric intensive care unit handover tool (PATHQS)

• DOI: 10.3389/fped.2024.1327381
• Publication Date: 2024-01-24T04:38:53Z
• Authors: D. Subramonian; G. Krahn; J. Wlodarczak; L. Lamb; S. Malherbe; E. Skarsgard; M. Patel
• Keywords: Mnemonic

Introduction Patient handover is a crucial transition requiring high level of coordination and communication. In the BC Children's Hospital (BCCH) pediatric intensive care unit (PICU), 10 adverse events stemming from issues that should have been addressed at operating room (OR) to PICU were reported into patient safety learning system (PSLS) within 1 year. We aimed undertake quality improvement project increase adherence standardized OR process 100% 6-month time frame. doing so, secondary aim was reduce by 50% same period. Methods The model for Plan, Do, Study, Act method used in this project. reviewed identify root causes. findings multidisciplinary inter-departmental group comprised members surgery, anesthesia, care. Issues batched themes address most problematic parts contributing risk. Intervention A bedside education campaign initiated familiarize team with an existing standard. then formulated new simplified visual tool mnemonic “PATHQS” where each letter denoted step addressing theme had noted pre-intervention work as events. Results Adherence 6 months improved 69% 92%. This sustained 12 3 years after introduction PATHQS. addition, there zero PSLS relating months, only one filed 36 months. Notably, staff self-reporting concerns during reduced 13% 0% years. PATHQS created also spread six other units hospital well adult teaching hospital. Conclusion built collaboratively between departments can improve safety. Simplification makes it adaptable applicable many different healthcare settings.