Implementation of a structured handoff program was associated with 23% fall in preventable adverse events.N Engl J Med. 2014;371:1803-1812.
Changes in medical errors after implementation of a handoff program.
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.
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.
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.
Health care worker fatigue and patient safety.
Sentinel Event Alert. December 14, 2011;(48):1-4.
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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.