terça-feira, 11 de novembro de 2014

Erro médico

Changes in Medical Errors after Implementation of a Handoff Program

Amy J. Starmer, M.D., M.P.H., Nancy D. Spector, M.D., Rajendu Srivastava, M.D., M.P.H., Daniel C. West, M.D., Glenn Rosenbluth, M.D., April D. Allen, M.P.A., Elizabeth L. Noble, B.A., Lisa L. Tse, B.A., Anuj K. Dalal, M.D., Carol A. Keohane, M.S., R.N., Stuart R. Lipsitz, Ph.D., Jeffrey M. Rothschild, M.D., M.P.H., Matthew F. Wien, B.S., Catherine S. Yoon, M.S., Katherine R. Zigmont, B.S.N., R.N., Karen M. Wilson, M.D., M.P.H., Jennifer K. O’Toole, M.D., M.Ed., Lauren G. Solan, M.D., Megan Aylor, M.D., Zia Bismilla, M.D., M.Ed., Maitreya Coffey, M.D., Sanjay Mahant, M.D., Rebecca L. Blankenburg, M.D., M.P.H., Lauren A. Destino, M.D., Jennifer L. Everhart, M.D., Shilpa J. Patel, M.D., James F. Bale, Jr., M.D., Jaime B. Spackman, M.S.H.S., Adam T. Stevenson, M.D., Sharon Calaman, M.D., F. Sessions Cole, M.D., Dorene F. Balmer, Ph.D., Jennifer H. Hepps, M.D., Joseph O. Lopreiato, M.D., M.P.H., Clifton E. Yu, M.D., Theodore C. Sectish, M.D., and Christopher P. Landrigan, M.D., M.P.H. for the I-PASS Study Group

N Engl J Med 2014; 371:1803-1812November 6, 2014DOI: 10.1056/NEJMsa1405556


Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking.


We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time–motion observations. The primary outcome had two components: medical errors and preventable adverse events.


In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient–family contact and computer time.


Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.)

Supported by grants from the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (1R18AE000029-01), the Agency for Healthcare Research and Quality/Oregon Comparative Effectiveness Research K12 Program (1K12HS019456-01, to Dr. Starmer), the Medical Research Foundation of Oregon, and the Physician Services Incorporated Foundation (of Ontario, Canada) and by an unrestricted medical education grant from Pfizer.
Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
The opinions and conclusions expressed herein are solely those of the authors and should not be construed as representing the opinions or policy of any agency of the federal government.

Source Information

From the Department of Medicine, Division of General Pediatrics, Boston Children’s Hospital (A.J.S., T.C.S., C.P.L., A.D.A., E.L.N., L.L.T.), Harvard Medical School (A.J.S., A.K.D., S.R.L., J.M.R., T.C.S., C.P.L.), Center for Patient Safety Research, Division of General Medicine (A.K.D., C.A.K., J.M.R., S.R.L., M.F.W., C.S.Y., K.R.Z.) and Division of Sleep Medicine (C.P.L.), Brigham and Women’s Hospital, and CRICO/Risk Management Foundation (C.A.K.) — all in Boston; the Department of Pediatrics, Doernbecher Children’s Hospital, Oregon Health and Science University, Portland (A.J.S., M.A.); the Department of Pediatrics, Section of General Pediatrics (N.D.S.) and Section of Critical Care (S.C.), St. Christopher’s Hospital for Children, Drexel University College of Medicine, Philadelphia; the Departments of Pediatrics (R.S., J.B.S., A.T.S.) and Neurology (J.F.B.), Primary Children’s Hospital, Intermountain Healthcare, University of Utah School of Medicine, and Institute for Health Care Delivery Research, Intermountain Healthcare (R.S.), Salt Lake City; the Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco (D.C.W., G.R.), and the Department of Pediatrics, Division of General Pediatrics, Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine, Palo Alto (R.L.B., L.A.D., J.L.E., S.J.P.) — both in California; the Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora (K.M.W.); the Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati (J.K.O., L.G.S.); the Department of Paediatrics (Z.B., M.C., S.M.), Centre for Quality Improvement and Patient Safety (M.C.), and Institute for Health Policy, Management and Evaluation (S.M.), Hospital for Sick Children and University of Toronto, Toronto; the Department of Pediatrics, Division of General Pediatrics, Kapi’olani Medical Center for Women and Children and University of Hawai’i John A. Burns School of Medicine, Honolulu, HI (S.J.P.); the Edward Mallinckrodt Department of Pediatrics, St. Louis Children’s Hospital and Washington University School of Medicine, St. Louis (F.S.C.); the Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston (D.F.B.); the Department of Pediatrics, Walter Reed National Military Medical Center (J.H.H., J.O.L., C.E.Y.) and the Val G. Hemming Simulation Center (J.O.L.), Uniformed Services University of the Health Sciences, Bethesda, MD.

Address reprint requests to Dr. Starmer at the Department of Medicine, Division of General Pediatrics, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, or at .
The members of the I-PASS Study Group are listed in the Supplementary Appendix, available at NEJM.org.

Nenhum comentário: