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
Background
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.
Methods
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.
Results
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.
Conclusions
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
amy.starmer@childrens.harvard.edu.
