Patient Handoff Medical Errors Can Be Reduced By I-PASS Program: Study

Implementing a program that focuses on improved verbal and written communication between healthcare providers during shift changes may great reduce the risk of serious and potentially life-threatening medical errors during patient handoffs, according to the findings of new research. 

In a study published this week by the New England Journal of Medicine, researchers from the Walter Reed National Military Medical Center and the Uniformed Services University of Health Sciences outlined the results of implementing the I-PASS Hand-off Bundle program at nine hospitals throughout the U.S. and Canada.

The patient handoff program improves communications and involves team training tools designed to specifically improve patient care during shift changes, or transferring care from one healthcare provider to another.

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Researchers evaluated data on the rates of medical errors, preventable injuries, miscommunications and resident workflow for a period of six months before implementing the I-PASS program and for six months post-intervention. Data on nearly 11,000 patient admissions were assessed between January 2011 and May 2013.

Using the I-PASS program, injuries due to medical errors were reduced by 30%. However, the rate of non-preventable injuries did not change much. Medical-error rates decreased by 23% from pre-intervention period to the post-intervention period. The improvements were seen across six of the nine hospital sites.

The risk of injury from medical errors is often increased when patients are being handed-off from one medical professional to another, specifically residents. Reduction in working hours for safety reasons has increased the frequency of handoffs, making patients more vulnerable during handoffs.

Miscommunication is the leading cause of serious injury due to medical errors, health experts say. Serious injuries often result in prolonged hospital stay, permanent disability and death.

“We recognized that it would take a great deal of work to make the handoff program a sustainable system and encourage its adoption across hospitals,” said Dr. Amy Starmer, lead author.

The researchers say a mandate requiring training for patient handoff has been lacking in healthcare, making the need for high quality communication between residents and staff members more crucial.

Handoff Program

The intervention program included seven key elements. The elements included, a mnemonic to standardize oral and written handoffs, handoff and communication training workshops, role-playing and simulation sessions, a computer module, faculty development program, direct-observation to provide feedback, and a sustainability campaign.

Error rates were measured using active surveillance and handoffs were assessed by evaluation of the printed handoff documents and audio recordings.

Workflow was assessed by using time-motion observations, this measured how much time the residents spent on activities, including computer work, conducting handoffs and direct patient care. Residents also completed surveys following every shift.

There was no change in residents’ time spent on usual activities as a result of the implementation of the handoff model. They did report more satisfaction in the quality of the handoffs.

“We took basic principles of patient safety and as a team found ways to integrate them into the normal workflow of hospital residents,” said Christopher Landrigan of Boston Children’s Division of General Pediatrics and co-author of the study. “We hope I-PASS will remain an embedded system within these institutions going forward.”


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