Importance
Miscommunication from multiple care transfer has been shown to increase morbidity and mortality. To mitigate adverse events, use of checklists to standardize handoff communications in post anesthesia care unit (PACU) has been studied and shown to effectively reduce medical errors. 
Objective
The goal is to establish measures to avoid miscommunication and improve patient safety through standardized PACU handoff protocol using a checklist.
Design
A total of 120 handoffs were observed by two research assistants in real time for pre-implementation and post-implementation of a handoff checklist. 60 handoffs were observed for each pre- and post-implementation period. Using a 12-item checklist, each observer quantified items reported during every observed handoff. Additional data points, such as: duration of the report, training of the anesthesia staff giving report, and total number of questions asked by PACU staff were collected for further analysis.
Setting
M6 surgical floor post anesthesia care unit (PACU) at Memorial Sloan Kettering Cancer Center (MSKCC).
Participants
120 handoffs were observed between June 13, 2016 and July 15, 2016 from 10AM to 5PM., which included observation of interactions between RN, PACU midlevel providers (nurse practitioners, physician assistant), attending anesthesiologists, certified nursing anesthetists (CRNAs), anesthesiology residents, CRNA students, attending surgeons, surgical fellows, surgical residents, and surgical PA-C. 
Intervention(s) for clinical trials or exposure(s) for observational studies
During pre-implementation period, all staff were not informed of the research agenda. Post-implementation period, electronic and physical copy of the checklist were distributed to anesthesia staff only. At every observed handoff, anesthesia staff were reminded to follow the order of items on the checklist.
Main outcome(s) and measure(s)
•	Overall data transfer increased from 9 to 11 items during handoff with a checklist. 
•	Median duration of handoff increased from 3 minutes to 4 minutes per handoff. 
•	Number of follow up questions asked by PACU staff stayed consistent pre- and post-implementation period. 
•	Improvements in data transfer were independent of anesthesia training. 
Results
•	Improvements in handoff were independent of duration of the report. The median number of 11 items stayed consistent through all lengths of reports.
•	Surgical staff reported consistently a median of 6 items during pre- and post-implementation periods, whereas anesthesia staff improved from 5 reported items to 9. Overall handoff improvement is likely due to anesthesia staff report. 
•	Data showed most improvement in anesthesia related items (ie. Allergies, Anesthesia Technique, and Airway) and least improvement in surgery related items (ie. Underlying diagnosis for the procedure, Procedure done, PACU plan, and Disposition).
•	40 out of 60 staff were not compliant in following the order of the list. However, the 20 handoffs that adhered to the order reported a median of 12 items.
Conclusions and Relevance
Implementation of a checklist for PACU handoff increased overall data transfer independent of duration of the report, improving patient safety. This result was noted across all trainings of anesthesia providers. For future directions, we recommend incorporating staff feedback into Plan-Do-Study-Act cycles for an improved checklist to ensure compliance and familiarize the staff with the use of a checklist through multimodal training modules.

Utilizing checklists to improve handoff in the Post Anesthesia Care Unit (PACU)