A recent study from researchers at Boston Children’s Hospital indicates that improvements in verbal and written communications during handoffs can reduce injuries due to medical errors by 30 percent.
The researchers examined the effectiveness of a system of bundled communication and training tools for handoffs patient care between providers. The tool, called I-PASS, encompasses communication and handoff training, a verbal handoff process organized around the verbal mnemonic "I-PASS" (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver), computerized handoff tools to share information between providers, engagement of supervising attending physicians during handoff, and a campaign promoting the adoption of I-PASS.
They looked at the implementation of I-PASS, which was developed by Christopher Landrigan, MD, MPH, of Boston Children's Division of General Pediatrics and his team of researchers, at pediatric residency programs of nine hospitals. At each participating hospital, patient handoffs by residents were monitored and assessed for a six-month pre-intervention period. During the six-month intervention phase, residents were trained on I-PASS handoff processes and required to use the system going forward. They then monitored handoffs following the intervention.
What they found, using data from 10,740 patient admissions, was the overall rate of medical errors decreased by 23 percent—from 24.5 to 18.8 errors per 100 admissions after I-PASS was introduced. Preventable adverse events (injuries due to medical errors) decreased by 30 percent—from 4.7 to 3.3 errors per 100 admissions.
"We took basic principles of patient safety and as a team found ways to integrate them into the normal workflow of hospital residents," Landrigan said in a statement. "We hope I-PASS will remain an embedded system within these institutions going forward."