Program May Lower Medical Errors‏ in Pediatric Hospitals

Laurie Barclay, MD

December 03, 2013

A program to improve handoff communication using a resident handoff bundle was associated with a significant reduction in medical errors in the pediatric hospital setting, according to a prospective intervention study published in the December 4 issue of JAMA.

"Traditionally, doctors are trained in medical school to interview a patient and write daily summaries of the care plan but though vital to patient care, [they] rarely receive communication or handoff training," lead author Amy J. Starmer, MD, MPH, from the Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, and the Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, said in a hospital news release. "We sought to rectify that omission with this study."

Because handoff miscommunications are a leading cause of medical errors, the Agency for Healthcare Research and Quality (AHRQ) and the Accreditation Council for Graduate Medical Education (ACGME) have identified improving handoffs as a nationwide priority. Although ACGME now requires formal instruction in handoffs as part of residency training, many institutions lack robust procedures for training residents or ensuring high-quality handoffs.

Therefore, the investigators examined whether implementing a multifaceted handoff program would be associated with lower rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, better verbal handoffs, and changes in resident–physician workflow.

This study took place on 2 inpatient units at Boston Children's Hospital from July through September 2009 (before implementation of the intervention) and November 2009 through January 2010 (after implementation of the intervention). The resident handoff bundle consisted of standardized communication and handoff training, a verbal mnemonic (I-PASS: I: illness severity, P: patient summary, A: action list, S: situation awareness and contingency planning, S: synthesis by receiver), and a new team handoff structure. One unit also used a computerized handoff tool linked to the electronic medical record.

Of 1255 patient admissions studied, 642 were before and 613 after the intervention, and of 84 resident physicians who admitted these patients, 42 did so before the intervention and 42 after the intervention.

Daily systematic surveillance allowed measurement of the main study endpoints of rates of medical errors (including those with little or no potential for harm, intercepted potential adverse events, and nonintercepted potential adverse events) and preventable adverse events. Omissions in the printed handoff document and resident time–motion activity were secondary outcomes.

Handoff Bundle Includes Several Strategies

To implement the new system, all participating clinicians attended an interactive workshop, including practice in giving and receiving handoffs under different clinical and real-world scenarios. Best practices for handoffs used elements of the TeamSTEPPS communication program, developed by the military and the AHRQ.

To ensure all relevant information was verbally communicated during the handoff, participants used the I-PASS mnemonic. Face-to-face handoffs were restructured to include all team members, integrate interns' and senior residents' separate handoffs into a unified team handoff, reduce interruptions and distractions, and introduce periodic handoff oversight by a chief resident or attending physician.

The investigators collaborated with Boston Children's informatics team to create a structured handoff tool within the electronic medical record for standardized documentation of the patient information that is transmitted at change of shift. Without this tool, clinicians have to manually enter and reenter information in a word processing document, which increases the potential for human error, whereas the electronic handoff tool self-populates with standard patient information.

Medical Error Rate Decreased After the Intervention

After the intervention, medical errors decreased from 33.8 per 100 admissions (95% confidence interval [CI], 27.3 - 40.3 errors) to 18.3 errors per 100 admissions (95% CI, 14.7 - 21.9 errors; P < .001). Preventable adverse events declined from 3.3 per 100 admissions (95% CI, 1.7 - 4.8 adverse events) to 1.5 per 100 admissions (95% CI, 0.51 - 2.4 adverse events; P = .04).

"We believed these systems would lead to a reduction in medical errors, but did not expect to see a change of this magnitude," Dr. Starmer said. "And even more surprising was that the systems were introduced so easily. Participants embraced the new system, became more productive, and could then focus more energy to the job at hand."

Although both units had fewer omissions of key handoff elements on printed handoff documents after the intervention, this was particularly true on the unit using the computerized handoff tool. Significant reductions of omissions occurred in 11 of 14 categories in that unit compared with 2 of 14 categories in the unit without the computerized tool.

"By introducing more standardized communication during patient handoffs for this study, Boston Children's saw a substantial drop in the overall number of medical errors," principal investigator Christopher Landrigan, MD, MPH, from the Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, and the Division of General Internal Medicine and the Division of Sleep Medicine, Brigham and Women’s Hospital, Harvard Medical School, said in the news release. "We believe if other medical centers adopted similar protocols it could have a positive and significant impact on patient safety."

After the intervention, physicians spent a greater percentage of each 24-hour period at the patient bedside (10.6% [95% CI, 9.2% - 12.2%] vs 8.3% [95% CI, 7.1% - 9.8%]; P = .03). There were no adverse effects on resident workflow, and the average duration of verbal handoffs per patient and time spent at the computer did not change.

Other improvements after the intervention were that verbal handoffs were more likely to occur in a quiet location (67.9% [95% CI, 50.6% - 85.2%] vs 33.3% [95% CI, 14.5% - 52.2%]; P = .03) and in a private location (85.7% [95% CI, 72.8% - 98.7%] vs 50.0% [95% CI, 30% - 70%]; P = .007).

Handoff Program Already Being Disseminated

On the basis of the study findings, the investigator developed I-PASS, a handoff bundle being introduced to 10 teaching hospitals across North America.

"Our ultimate goal," Dr. Landrigan said in the news release, "is to develop a robust handoff program that can be broadly disseminated across hospitals and specialties to reduce medical errors and optimize patient safety."

In an accompanying editorial, Leora Horwitz, MD, MHS, from the Yale School of Medicine in New Haven, Connecticut, calls this "the most comprehensive study of the direct effects of handoff interventions on outcomes within the context of existing work-hour regulations."

Dr. Horwitz notes numerous study limitations, including the uncontrolled, before-and-after design; lack of blinding of the nurses collecting adverse event data; possible unmeasured confounding or random variation; and relatively brief follow-up time period of 3 months. In addition, implementation of the entire bundle made it impossible to determine which, if any, elements were more effective than others.

"As hospitals and residency programs seek to manage increasing complexity and fragmentation without reverting to an archaic model of round-the-clock care, the focus will be on safe handoffs and mitigating discontinuity," Dr. Horwitz writes. "[This study] presents tantalizing evidence that improving handoffs can actually reduce harm to patients. In the meantime, while awaiting results from larger multi-institutional studies, it is reasonable to ensure that at least basic elements of safe handoffs are in place."

This study was supported by the Controlled Risk Insurance Company Risk Management Foundation Grant Program and a grant from the Boston Children's Hospital Program for Patient Safety and Quality Research. Dr. Starmer was supported by grants and a National Research Service Award in Pediatrics from the Oregon Comparative Effectiveness Research K12 Program through the Agency for Healthcare Research and Quality. Dr. Landrigan has reported receiving monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for delivering lectures on sleep deprivation, physician performance, handoffs, and safety and is partially supported by the Child Health Corporation of America. The other authors and Dr. Horwitz have disclosed no relevant financial relationships.

JAMA. 2013;310(21):2255-2256, 2262-2270.

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