Evaluation of Intraoperative Hand-Off Frequency, Duration, and Context: A Mixed Methods Analysis

Lane L. Frasier, Sudha R. Pavuluri Quamme, Douglas Wiegmann, Caprice C. Greenberg

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Background: Hand-offs in the operating room contribute to poor communication, reduced team function, and may be poorly coordinated with other activities. Conversely, they may represent a missed opportunity for improved communication. We sought to better understand the coordination and impact of intraoperative hand-offs. Methods: We prospectively audio-video (AV) recorded 10 operations and evaluated intraoperative hand-offs. Data collected included percentage of time team members were absent due to breaks, relationships between hand-offs and intraoperative events (incision, surgical counts), and occurrences of simultaneous hand-offs. We also identified announcement that a hand-off had occurred and anchoring, in which team members not involved in the hand-off participated and provided information. Results: Spanning 2919 min of audio-video data, there were 74 hand-offs (range, 4-14 per case) totaling 225.2 min, representing 7.7% of time recorded. Thirty-two (45.1%) hand-offs were interrupted or delayed because of competing activities; eight hand-offs occurred during an instrument or laparotomy pad count. Six cases had simultaneous hand-offs; two cases had two episodes of simultaneous hand-offs. Eight hand-offs included an announcement. Seven included anchoring. Evaluating both temporary and permanent hand-offs, one or more original team members was absent for 40.7% of time recorded and >one team member was absent for 20.5% of time recorded. Conclusions: Intraoperative hand-offs are frequent and not well coordinated with intraoperative events including counts and other hand-offs. Anchoring and announced hand-offs occurred in a small proportion of cases. Future work must focus on optimizing timing, content, and participation in intraoperative hand-offs.

Original languageEnglish (US)
Pages (from-to)124-130
Number of pages7
JournalJournal of Surgical Research
StatePublished - Dec 2020
Externally publishedYes


  • Communication
  • Intraoperative hand-offs
  • Teamwork
  • Transitions in care

ASJC Scopus subject areas

  • Surgery


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