Implementation of an Electronic Checklist to Improve Patient Handover From Ward to Operating Room Kristine H. Münter, MD,* Thea P. Møller, MD,† Doris Østergaard, MD,† and Lone Fuhrmann, MD, BSc, PhD* Objective: Research has identified numerous safety risks in perioper- ative patient handover. In handover from ward to operating room (OR), patients are often transferred by a third person. This adds to the risk of loss of important information and of caregivers in the OR not identify- ing possible risk factors. The aim of this study was to describe the imple- mentation process and completion rate of a new preoperative, ward-to-OR checklist. Our goal was a 90% fulfillment. Method: This study is a prospective, observational study in a Danish University Hospital including all patients undergoing surgery in 2013. The checklist was a screen page with 27 checkboxes of information rele- vant for a safe handover. The checklist should be completed in the ward before handover to the OR and should be checked in the OR before re- ceiving the patient. The Plan-Do-Study-Act (PDSA) cycle method was used in the implementation process of the checklist. Results: A total of 17.361 patients were included. In wards with only elective surgery (plastic and breast surgery), the checklist was used in 1.419 of 2.286 patients (62.1%). In wards with both elective and emergency surgery (abdominal, orthopedic, urology, gynecology and obstetrics), the checklist was used in 1.963 of 7.460 elective patients (26.3%) and in 812 of 7.615 emergency patients (10.7 %). Conclusion: Our goal of a 90% fulfillment was not reached. The electronic checklist seemed to be used most frequently in wards with only elective surgery. Key Words: patient safety, implementation, patient handover, quality improvement (J Patient Saf 2017;00: 00–00) H ospitalized patients often change care settings, resulting in transfer of responsibility between caregivers. Risks related to these patient handovers are identified. 1–3 Several studies have investigated the handover from operating room (OR) to recovery room 3–7 and highlighted the importance of safe transfer of patients into the vulnerable postoperative phase. The handover from the surgical ward to the OR (the “preoperative handover”) is, however, less explored. One study found incomplete handover from ward to OR in 67% of cases, the most frequent causes being due to primitive information transfer and lack of guidelines, possibly leading to increased morbidity and mortality. 8 Another study showed that only 27% of patient information reached the OR team members and that 75% of the patients experienced adverse events because of insufficient information transfer and commu- nication failures. 9 Most research has focused on handovers with direct verbal communication between caregivers. However, in the preoperative handover, communication is often non-verbal. Consequently, there is a risk of information loss, and insufficient preoperative preparation of patients may pass unattended. Even with ade- quate preoperative preparation, insufficient documentation is a setback for the OR team, since valuable time may be spent obtaining missing information about medication, blood tests, etc. Lack of safety procedures or tools that can help caregivers to avoid or correct these violations increases the risk of harming the patient. 10,11 The World Health Organization's surgical checklist used be- fore, during, and at the end of the surgical procedure has shown to increase patient safety. 12 We developed an electronic preopera- tive checklist for the preoperative handover in accordance with recommendations in the literature. 13,14 This was to improve the transfer of information and to avoid insufficient preparation of the patient. There is an increasing focus on the challenges of im- plementation and use of checklists and barriers of using checklists' full potential. 15 Improving preoperative handover is an orga- nizational change and a challenge because it implies change across departments. A failure rate of approximately 70% of all change programs initiated is reported, and this may be due to a lack of a valid framework of how to implement and manage organizational change. 16 In this study, we describe the implementation process and the completion rate of an electronic preoperative checklist. Our goal was a 90% completion rate. METHODS Setting The study was a prospective, observational study including all patients undergoing surgery in 2013. The study was performed at a Danish university hospital with more than 17,000 surgical procedures performed annually covering emergency and elective procedures within urology, gynecology and obstetrics, orthopedic, abdominal, breast, and plastic surgery. Danish law exempts this type of study from ethical approval. Development of the Checklist A checklist addressing 27 items of information necessary for a safe preoperative handover (Fig. 1) was developed through 2 interactive table simulation–based workshops involving the different professions and specialties involved in preoperative handovers. In the first workshop, the patient flow was mapped, and in the second workshop, the challenges and solutions in the patient trajectory were identified. The solutions were education of staff and use of checklist to facilitate a safe and structured communication. This is described in a previous paper. 13 The check- list was based on the hospital's guidelines for safe handling of surgical patients and recommendations in the literature. It consisted of a single screen page with checkboxes incorporated in the electronic patient management system. In the preoperative handover, the senders of patients were the caregivers in the surgical wards; and the receivers were the teams in the OR comprising surgeons, scrub nurses, nurse anesthetists, and anesthesiologists. The ward caregivers were obliged to fill out From the *Department of Anaesthesiology and Intensive Care, Herlev Hospital, University of Copenhagen, Denmark; and †Danish Institute for Medical Simu- lation, University of Copenhagen, Denmark. Correspondence: Kristine Husum Münter, MD, Department of Anaesthesiology, Herlev Hospital, Herlev Ringvej 75 DK-2730 Herlev, Denmark (e‐mail: Kristinemunter@gmail.com). The authors disclose no conflict of interest. Funding received for this work was departmental only. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. ORIGINAL ARTICLE J Patient Saf • Volume 00, Number 00, Month 2017 www.journalpatientsafety.com 1 Copyright © 2017 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Copyright © 2017 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.