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June 2010
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Tacit Handover, Overt Mishap
Commentary by Jeffrey B. Cooper, PhD; Brinda B. Kamdar, MD

The Case


A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdominal aortic aneurysm. In preparation for surgical removal of the infected stent and graft repair of the abdominal aorta, a spinal drain was placed by an anesthesiologist. The spinal drain, a small soft catheter, was inserted into the lower spinal cord to remove cerebrospinal fluid—these drains lower pressure in the spinal cord and thereby reduce the risk for post-surgery paralysis.

The patient underwent uncomplicated removal of the infected stent and graft repair of the aorta. Per protocol, the spinal drain remained in place for 48 hours after the procedure. At that time, the anesthesiologist attempted to remove the drain, but aggressive pulling resulted only in stretching of the catheter. Concerned about causing injury to the patient, he consulted a neurosurgeon who recommended that further attempts to remove the catheter be done under general anesthesia in the operating room (OR) in hopes that anesthesia would relax the back muscles. The patient was placed on the OR schedule for the following day. The anesthesiologist and neurosurgeon both clearly documented the plan of care in the chart.

The following morning, the five anesthesiologists on duty met to discuss all of the cases scheduled for the day, including the catheter removal, so all of them were aware of the plan. Unfortunately, because of prolonged surgeries, the case was pushed to the end of the day. By that point, the anesthesiologist on call for the night had arrived, unaware of any of the treatment plans. She noticed that this case was labeled "Spinal Drain Removal" on the schedule. Confident that she knew how to manage these devices, she approached the head anesthesiologist for the day and asked if she could "take care of the spinal drain case." The head anesthesiologist knew that she had experience in the area and simply said "yes" without conveying any further information. The on-call anesthesiologist did not review the patient's chart or obtain any further information.

Unaware of the plan for general anesthesia, the on-call anesthesiologist proceeded to try to pull out the drain while the patient was awake in the preoperative area. Unfortunately, the catheter broke, leaving a portion inside the spinal canal. Consequently, the neurosurgeon had no choice but to surgically remove the catheter. Luckily, the patient suffered no major consequences, but was at risk for spinal cord injury and had to undergo a second surgical procedure.

The Commentary

by Jeffrey B. Cooper, PhD; Brinda B. Kamdar, MD

While there is something to be learned about the proper care of spinal catheters from this case, the most important issue to discuss is the handoff, the transition of care between providers, which clearly was subpar and led to an adverse patient outcome.

Transfers of responsibility from one provider or team to another—the handoff (the terms handover and shift transfer are also used, although not all handoffs are shift transfers)—are common in anesthesia, especially for periodic short breaks and during long procedures that span shifts. Other handoffs occur as patients move to and from the floor, preoperative assessment and induction areas, emergency department, ICU, and post-anesthesia care unit (PACU). Good data are not available on rates of adverse events associated with anesthesia handoffs. A classic study (1) identified various kinds of errors that occur as a result of poor handoffs. Among those were incorrect drug or dose administered, hypovolemia, and switch to a contraindicated technique.

It is worth placing that 1982 study in context. In that era, it was expected that anesthesia professionals, like surgeons, would stay with their patients through the entire procedure. We now recognize that such long, unbroken periods of work create fatigue and opportunities for error. Moreover, the study pointed out that a break can have collateral benefits—specifically that the incoming provider sometimes identifies a problem that was not recognized by the person being replaced.

With implementation of short breaks and, more recently, duty hour limits, the frequency of handoffs has increased, in anesthesia and other areas of medicine. Recent studies have re-focused attention on the errors and patient harm associated with handoffs and how best to protect patients during these events.(2-6)

The challenges presented by handoffs in anesthesia are not fundamentally different from those in other specialties. The critical issue is that the outgoing provider(s) has both explicit and, perhaps more important, tacit knowledge about the patient that is not easily conveyed to the incoming provider(s). Philibert recently reported on the types of handoff practices in high-reliability organizations and those medical specialties that have focused on improving the handoff process.(2) Practices to enhance the handoff included: both the incoming as well as the outgoing clinician decided on topics and information to be discussed; the incoming provider directly assessed the current status of the patient; and information was communicated in a consistent order every time. Strategies recommended by experts but generally not used by residents included limiting interruptions during the handoff, reading back to confirm the accuracy of information received, and observing the incoming resident's work following the update.

In anesthesia handoffs, the two providers almost always speak face to face, one of the most important safety practices. However, there are a number of challenges that are specific to anesthesia handoffs, including the frequent presence of an active procedure (one that is underway, not so in the case presented here), non-standard drug preparations, and various types of personal, non-standard practices and preferences. For instance, anesthetists in the same facility typically have at least some individual drug preferences of type or dose and may label drugs in different, non-standard ways. For instance, the incoming might have a routine of diluting a narcotic to a specific concentration, but the person she or he is replacing uses another. In the face of a distraction or multi-tasking, it's not difficult to imagine a mental lapse in reading the label (if it is labeled; while a requirement, it isn't always done) or assuming it is a concentration different from what it actually is.

Hindsight allows us to see that the on-call anesthesiologist in this case neglected several clues that this case was not a routine spinal drain removal. Spinal drains are not typically removed in the OR setting, so the fact that this was a "scheduled" case should have prompted a more thorough investigation and discussion by the anesthesiologist. In addition, for all routine spinal drain removals, a coagulation panel needs to be reviewed and corrected if abnormal (we don't know if that was done here). Also, the patient's medication list needs to be assessed prior to manipulation of a spinal drain. Standard guidelines dictate that systemic anticoagulant therapy or low-molecular-weight heparin thromboprophylaxis be held to prevent epidural hematoma and potential neurologic complications. These last two tasks would necessitate a chart review and further investigation that could have potentially prevented the complication that occurred.

It is unclear why the above steps apparently were neglected, which should make us wonder if other elements could have contributed to this poor handoff. Certainly there is a strong human element that may have thwarted good handoff practices. It can be difficult to ask what may appear to be obvious questions, such as why this patient was placed on the OR schedule. That can happen especially when there is an authority gradient, making the questioner even more reluctant to demonstrate "ignorance." Lack of knowledge may also have contributed to this complication. Shearing of catheters is an underappreciated complication of spinal drain placement and removal.(7) Commonly cited reasons in the literature for this complication include withdrawing the catheter through the bevel of the needle, using excessive force in removing or threading the catheter, improper use of the guidewire, and more rarely, flaws in the integrity of the catheter itself due to manufacturing defects. Perhaps the on-call anesthesiologist had not appreciated this potential complication.

Despite the clear potential for errors in association with anesthesia handoffs and the publication of a handoff protocol more than 20 years ago (8), anesthesia handoffs are probably not standardized within most facilities. One barrier is "production pressure," which pushes clinicians to keep the patients moving through the system quickly. The resistance to adopting standardized tools in general and to any changes from existing cultural norms is also a strong barrier to changing behaviors. The data demonstrating the risk in anesthesia have not been visible enough to warrant forcing such standards on physicians, who are generally reluctant to follow imposed mandates.

This state of affairs may be changing. A multispecialty "Transfer of Care (TOC) Patient Safety Initiative for Anesthesia Professionals" has been formed to recommend standard handoff practices (J. Jeffrey Andrews, MD, University of Texas Health Science Center at San Antonio; written communication; April 1, 2010). We can only hope that this will soon lead to more effective handoffs in anesthesia. Fundamentally, handoffs should become a sacred ritual, as common as the checklist in a cockpit, in which the incoming provider also asks questions to elicit potentially undocumented or unusual circumstances. The basic question should be: "Is there anything unusual I need to know about this patient or procedure or what's going on currently that might impact what I do or how I do it?" This sounds so simple. But when things generally go well, and when production pressure is routine, providers can become complacent about risks. Or, if they generally are vigilant about those risks, there are times when a handoff can become rushed. Yet in a culture in which safety is truly the highest priority, the handoff ritual will never be skipped. And providers will be trained to do it, perhaps best via simulation.(9,10)

The data elements of a good handoff have been described in the literature (11), but the process and underlying culture are probably more important than the elements. As Smith and colleagues suggested in their study of handoffs from anesthetists to PACU nurses, "While standardized processes are advocated, they will likely work best when the informal elements, and the culture factors underlying them, are acknowledged."(12)

In fact, we may have the basic handoff process wrong. For example, should the outgoing person report first or the incoming review a list and ask questions? We'll hopefully learn more in the near future from ongoing studies.(13) In the meantime, it's prudent to adopt a local protocol for what information should be transferred, in what order, and in what formal ways. As cases like this one teach us, to do less no longer makes sense.

Take-Home Points

  • Handoffs in anesthesia, especially for atypical procedures and complex patients, are a time of increased risk but may also have potential benefit (from a fresh pair of eyes and relieving a fatigued provider).
  • With strong practices and culture, the risks of handoffs can be minimized and benefits optimized.
  • Some form of standardized handoff protocol and process should be adopted and implemented in all anesthesia practices.
  • The protocol should aim to leave the incoming anesthesiologist equivalent to the outgoing in both explicit and tacit knowledge of the patient.

Jeffrey B. Cooper, PhD
Professor of Anaesthesia

Harvard Medical School

Massachusetts General Hospital

Executive Director

Center for Medical Simulation

Brinda B. Kamdar, MD
Instructor of Anaesthesia

Harvard Medical School

Massachusetts General Hospital


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8. Cooper JB. Do short breaks increase or decrease anesthetic risk? J Clin Anesth. 1989;1:228-231. [go to PubMed]

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11. Goldhaber-Feibert S, Cooper JB. Safety in anesthesia. In: Levine WC, Allain RM, Alston TA, Dunn PF, Kwo J, eds. Clinical Anesthesia Procedures of the Massachusetts General Hospital: Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School. Philadelphia, PA: Lippincott Williams and Wilkins; 2007:127-134. ISBN: 9781605474601.

12. Smith AF, Pope C, Goodwin D, Mort M. Interprofessional handover and patient safety in anaesthesia: observational study of handovers in the recovery room. Br J Anaesth. 2008;101:332-337. [go to PubMed]

13. Brull SJ. Grant program funds five awards. Anesthesia Patient Safety Foundation Newsletter. 2007;21:69-71. Accessed May 27, 2010.