Medical Errors Can Be Reduced With Improved Patient Handoffs: Study

New research suggests that the risk of medical mistakes associated with the transfer of care from one medical team to another can be significantly reduced by implementing simple interventions during patient handoffs.

In s study published in the Journal of the American Medical Association (JAMA) on December 4, researchers examined data from Boston Children’s Hospital and Harvard Medical School in Boston and found fewer medical errors were made after an intervention program was implemented for doctors.

The intervention program focused on patient handoffs, a term for a change in staff while caring for a patient. Some experts say handoff communication errors are a leading cause of unexpected medical mistakes resulting in death or physical injury.

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Researchers found that after introducing a multifaceted program among physicians-in-training, medical mistakes decreased from nearly 34 per 100 admissions to 18 per 100 admissions, and preventable adverse events were also reduced from 3.3 per 100 admissions to 1.5.

The program included 1,255 patients, 642 before the intervention and 613 after, and 84 resident physicians, 42 before the intervention and 42 after. Two inpatient units at Boston Children’s Hospital were studied from July to September 2009 and November 2009 to January 2010.

An editorial published in JAMA by Leora I. Horwitz commented on the article and discussed the increase in patients, work hours and focus on patient care over the last 50 years. Practicing medicine was once viewed as a round the clock job for physicians. Now physicians are recommended to work less hours, which results in an increase in the frequency and need of handoffs to other physicians.

Intervention Focused on Communication

Amy J. Starmer, M.D. and a team of researchers completed a two-hour communication training session with the two units receiving interventions.

The intervention session included information about best practices for verbal and written handoffs, introduction of memory aids, restructuring of verbal handoffs into a unified team handoff and relocation of handoff oversight.

One inpatient unit was provided with a computerized handoff tool which integrated electronic medical records.

Researchers found fewer omissions were committed during staff change in the unit which received the computerized training tool. The team found a reduction in 11 of 14 categories compared to reductions in only two of 14 categories without the computerized tool.

The study also revealed after receiving training patient handoffs were more likely to occur in a quiet and private location. In addition, the team found doctors began to spend more time at a patient’s bedside following the intervention.

“Implementation of a handoff bundle was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children,” wrote the Starmer. “Improvements in verbal and written handoff processes occurred, and resident workflow did not change adversely.”


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