Improved Patient Handoffs Reduce Hospital Errors

Improvements in verbal and written communication between health care providers during patient handoffs can reduce injuries due to medical errors by 30%, according to a new study.

Researchers at Boston Children's Hospital (MA, USA), Intermountain Healthcare (Salt Lake City, UT, USA), and other institutions conducted a prospective intervention study of the I-PASS (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver) resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. 

Interventions included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance, while handoffs were assessed by evaluation of printed handoff documents and audio recordings; workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events.

The results showed that in 10,740 patient admissions, medical errors decreased by 23% in the post-intervention period, and the rate of preventable adverse events decreased by 30%; the rate of nonpreventable adverse events did not change significantly, remaining at about three events per 100 admissions. Significant increases were observed in all prespecified key elements during handoff (i.e., nine written documents and five oral communications). Time-motion analysis showed that implementing I-PASS did not add time to patient handoffs, and did not decrease time spent at patient bedsides or on other tasks. The study was published on November 6, 2014, in the New England Journal of Medicine (NEJM).

“Because we know that miscommunications so commonly lead to serious medical errors, and because the frequency of handoffs in the hospital is increasing, there is no question that high-quality handoff improvement programs need to be a top priority for hospitals,” said lead author Amy Starmer, MD, MPH. “It's tremendously exciting to finally have a comprehensive and rigorously tested training program that has been proven to be associated with safer care and that meets this need for our patients.”

Medical errors in hospitals such as diagnostic delays, preventable surgical complications, and medication overdoses are a leading cause of death and injury. An estimated 80% of the most serious medical errors are linked to communication between clinicians, particularly during patient handoffs. For example, a handoff-related medical error could occur if information about a critical diagnostic test is not communicated correctly between providers at shift change; the result could be a potentially harmful delay in patient care.

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Boston Children's Hospital