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Objective <p>Transitions of care are critical periods when NICU patients are at risk for miscommunication leading to patient harm. This quality improvement project aimed to decrease post-operative hand-off-related failures and improve communication in a level IV NICU.</p> Project design <p>The Vermont Oxford Network transitions of care framework was used to develop a safe surgical hand-off definition; (1) all team members present, (2) a structured hand-off format utilized, and (3) an environment conducive for hand-off. Interventions included using standardization for process improvement, scripting ideal communication, and simulation to establish behavioral norms of effective communication.</p> Results <p>Post-surgical hand-off-related care failures decreased from 75% pre-implementation to 6% post-implementation (<i>p</i> &lt; 0.00001) by increasing the percentage of hand-offs meeting pre-defined criteria.</p> Conclusion <p>Using quality improvement methods to implement process and behavioral changes to improve communication, our team reached our goal of decreasing post-operative hand-off-related care failures.</p>

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A quality improvement project improving post-operative transitions of care in a level IV NICU

  • 期刊论文

  • 发表日期：

    2025年2月27日

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  • Hannah Fischer,
  • Diane Buckley,
  • Jessica Ford,
  • John Juneau,
  • Daniel Kahn,
  • Carrie Moore,
  • Julia Springate Spalding,
  • Tamina Singh

摘要

Objective

Transitions of care are critical periods when NICU patients are at risk for miscommunication leading to patient harm. This quality improvement project aimed to decrease post-operative hand-off-related failures and improve communication in a level IV NICU.

Project design

The Vermont Oxford Network transitions of care framework was used to develop a safe surgical hand-off definition; (1) all team members present, (2) a structured hand-off format utilized, and (3) an environment conducive for hand-off. Interventions included using standardization for process improvement, scripting ideal communication, and simulation to establish behavioral norms of effective communication.

Results

Post-surgical hand-off-related care failures decreased from 75% pre-implementation to 6% post-implementation (p < 0.00001) by increasing the percentage of hand-offs meeting pre-defined criteria.

Conclusion

Using quality improvement methods to implement process and behavioral changes to improve communication, our team reached our goal of decreasing post-operative hand-off-related care failures.