domingo, 16 de noviembre de 2014

AHRQ Patient Safety Network ▲ Changes in medical errors after implementation of a handoff program.

AHRQ Patient Safety Network

Implementation of a structured handoff program was associated with 23% fall in preventable adverse events.N Engl J Med. 2014;371:1803-1812.

PSNet header image
Changes in medical errors after implementation of a handoff program. Classic icon
Starmer AJ, Spector ND, Srivastava R, et al; I-PASS Study Group. N Engl J Med. 2014;371:1803-1812.
The number of handoffs a patient experiences while hospitalized has almost certainly increased at academic institutions after the implementation of duty hour restrictions, posing a significant threat to patient safety. In response, The Joint Commission required that all hospitals maintain a standardized approach to handoff communication, and in 2010 the Accreditation Council for Graduate Medical Education required that all residents receive formal handoff training. This multicenter study demonstrates that implementation of a standardized handoff bundle—which included a mnemonic ("I-PASS") for standardized oral and written signouts, formal training in handoff communication, faculty development, and efforts to ensure sustainability—was associated with a 23% relative reduction in the incidence of preventable adverse events across 9 participating pediatric residency programs. This improvement was achieved through a very high level of resident engagement in the revised handoff process, but did not negatively affect resident workflow. This rigorously designed and analyzed study establishes the I-PASS model as the gold standard for effective clinical handoffs and demonstrates the value of methodologically stringent approaches to addressing patient safety issues. A case of a delayed diagnosis due to poor handoffs is discussed in a past AHRQ WebM&Mcommentary.
PubMed citation icon indicating hyperlink to external website
Available at icon indicating hyperlink to external website
Related news article icon indicating hyperlink to external website

Related Resources
STUDY
Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes.
Helms AS, Perez TE, Baltz J, et al. J Gen Intern Med. 2012;27:287-291.
STUDY
Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.
Payne CE, Stein JM, Leong T, Dressler DD. BMJ Qual Saf. 2012;21:925-932.
ORGANIZATIONAL POLICY/GUIDELINES
Health care worker fatigue and patient safety.
Sentinel Event Alert. December 14, 2011;(48):1-4.
STUDY
Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist.
Greenstein EA, Arora VM, Staisiunas PG, Banerjee SS, Farnan JM. BMJ Qual Saf. 2013;22:219-224.
View all related resources...

No hay comentarios: