Web-Based Handoff Tool and Training Linked to Fewer Errors

Marcia Frellick

August 05, 2016

Implementation of a web-based handoff tool and workshop for healthcare professionals at a Massachusetts hospital was associated with significantly fewer medical errors, particularly those linked with poor communication, new data show.

Stephanie K. Mueller, MD, MPH, from the Division of General Internal Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, and colleagues conducted a prospective cohort analysis at the hospital from November 1, 2012, to February 1, 2014.

Data were analyzed from patients on three general medicine services and two general surgery services during a single period 4 months before implementing the tool and two 4-month periods after implementation. (Between periods 2 and 3, general medicine services, but not surgical services, were restructured to regionalized care teams.)

Among the 5407 total patients in the study, 77 medical errors were detected before the intervention vs 45 after the intervention, Dr Mueller and colleagues report in a research letter published online August 1 in JAMA Internal Medicine.

Key components of the intervention were autopopulation of patient information from the existing electronic health record, such as resuscitation preferences and demographic information, templated fields with prompts to include key pieces of information, streamlining so that handoff updates were done at the same time as progress notes, training for healthcare professionals (all medical and surgical residents, medical hospitalists, and surgical chief residents) on use of the tool and in communication and teamwork using TeamSTEPPS, training of a champion to reinforce proper use, and weekly handoff feedback.

Validated surveillance surveys were given to night shift residents (12 am - 7 am) and "twilight" shift residents (4 pm - 12 am) as they completed their shifts and to residents and attendings 2 days after they started their general medical or surgical service. The surveys asked about potential errors, and those were followed by targeted review of medical records.

The three periods of data collection included preimplementation, postimplementation, and postimplementation matched to preimplementation by time of year (to account for potential effects of resident experience.)

There were significant reductions in total medical error rates per 100 patient-days (period 1 rate: 3.56; 95% confidence interval [CI], 1.70 - 7.44; period 2 and 3 rate: 1.76; 95% CI, 0.93 - 3.31; P < .001).

In addition, errors resulting from communication failures dropped significantly (period 1 rate: 2.88 per 100 patient-days; 95% CI, 1.22 - 6.82; period 2 and 3 rate, 1.15; 95% CI, 0.76 - 1.74; P < .001), as did errors from mistakes in handoffs (period 1 rate, 2.47; 95% CI, 1.00 - 6.07; period 2 and 3 rate, 0.95; 95% CI, 0.56 - 1.61; P < .001), and errors from end-of-shift (but not end-of-rotation) handoffs (period 1 rate, 6.93; 95% CI, 5.36 - 8.76; period 2 and 3 rate, 3.59; 95% CI, 2.55 - 4.87; P = .001).

"In addition, we saw a stepwise reduction in rates of errors on general medicine services, suggesting that regionalization between periods 2 and 3 had an additive or synergistic effect, supported by the fact that this reduction was not replicated on surgical services," the authors write.

Changes during regionalization included that medical teams were localized to a single nursing unit and that there was a dedicated 1-hour overlap between day and twilight teams for handoff of care and resident education.

Hard to Separate Benefit of Tool From Workshop

In an invited commentary, Adam J. Schoenfeld, MD, and Robert M. Wachter, MD, from the Department of Medicine, University of California, San Francisco, said it is important to consider possible confounding because the physicians also attended handoff and communication workshops when the tool was being rolled out.

"[T]hese workshops—rather than the handoff tool itself—may have led to the decrease in rates of errors," they write, adding that it is possible the combined effect may be important.

They note that unlike this study, prior studies have not detailed the specifics of the handoff tools and key features that may have led to success.

Dr Schoenfeld and Dr Wachter write that it is unlikely one handoff tool will work in all hospital settings, but features such as autopopulating key fields from the electronic health record are bound to increase satisfaction and efficiency and reduce errors in communicating information such as medication orders and resuscitation preferences.

Future studies should measure whether handoff tools affect mortality, length of stay, rates of adverse events, physician satisfaction, and communication errors, they conclude.

This research was supported by funds within the Department of Medicine, Brigham and Women's Hospital. One coauthor of the research letter reports funding from sanofi aventis for an investigator-initiated study to design and evaluate an intensive discharge and follow-up intervention in patients with diabetes. The other authors have disclosed no relevant financial relationships. Dr Wachter reported serving as a member of the Lucian Leape Institute of the National Patient Safety Foundation (for which he receives no compensation); currently serving as chair of an advisory board to England's National Health Service reviewing their digital health strategy (no compensation); entering into a contract to the University of California, San Francisco from the Agency for Healthcare Research and Quality to edit a patient-safety website; receiving compensation from John Wiley & Sons for writing a blog; receiving royalties from Lippincott Williams &Wilkins and McGraw-Hill for writing and editing several books; receiving a stipend and stock or stock options for having previously served on the Board of Directors of IPC Healthcare (ended in 2015); receiving stock options for serving on the board of Acuity Medical Management Systems; serving on the scientific advisory boards for Amino.com, PatientSafe Solutions, QPID Health, Twine, and EarlySense (for which he receives stock options); holding a royalty stake in CareWeb, a hospital communication tool developed at the University of California, San Francisco; and holding the Benioff endowed chair in hospital medicine. Dr Schoenfeld has disclosed no relevant financial relationships.

JAMA Intern Med. Published online August 1, 2016. Letter extract, Commentary extract

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