Maitreya Coffey

Changes in medical errors after implementation of a handoff program

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.).

Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study

Background: Limited data are available on adverse events among children admitted to hospital. The Canadian Paediatric Adverse Events Study was done to describe the epidemiology of adverse events among children in hospital in Canada. Methods: We performed a 2-stage medical record review at 8 academic pediatric centres and 14 community hospitals in Canada. We reviewed charts from patients admitted from April 2008 through March 2009, evenly distributed across 4 age groups (0 to 28 d; 29 to 365 d; > 1 to 5 yr and > 5 to 18 yr). In stage 1, nurses and health records personnel who had received training in the use of the Canadian Paediatric Trigger Tool reviewed medical records to detect triggers for possible adverse events. In stage 2, physicians reviewed the charts identified as having triggers and described the adverse events. Results: A total of 3669 children were admitted to hospital during the study period. The weighted rate of adverse events was 9.2%. Adverse events were more frequent in academic pediatric centres than in community hospitals (adjusted odds ratio [OR] 2.98, 95% confidence interval [CI] 1.65–5.39). The incidence of preventable adverse events was not significantly different between types of hospital, but nonpreventable adverse events were more common in academic pediatric centres (adjusted OR 4.39, 95% CI 2.08–9.27). Surgical events predominated overall and occurred more frequently in academic pediatric centres than in community hospitals (37.2% v. 21.5%, relative risk [RR] 1.7, 95% CI 1.0–3.1), whereas events associated with diagnostic errors were significantly less frequent (11.1% v. 23.1%, RR 0.5, 95% CI 0.2–0.9). Interpretation: More children have adverse events in academic pediatric centres than in community hospitals; however, adverse events in the former are less likely to be preventable. There are many opportunities to reduce harm affecting children in hospital in Canada, particularly related to surgery, intensive care and diagnostic error.

Families as Partners in Hospital Error and Adverse Event Surveillance

Importance Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection. Objective To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports. Design, Setting, and Participants We conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; &kgr;, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient. Main Outcomes and Measures Error and AE rates. Results Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P = .006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates. Conclusions and Relevance Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better design and assessment of interventions to improve safety.

Resident Experiences With Implementation of the I-PASS Handoff Bundle

BACKGROUND The I-PASS Handoff Study found that introduction of a handoff bundle (handoff and teamwork training for residents, a mnemonic, a handoff tool, a faculty development program, and a sustainability campaign) at 9 pediatrics residency programs was associated with improved communication and patient safety. OBJECTIVE This parallel qualitative study aimed to understand resident experiences with I-PASS and to inform future implementation and sustainability strategies. METHODS Resident experiences with I-PASS were explored in focus groups (N = 50 residents) at 8 hospitals throughout 2012-2013. A content analysis of transcripts was conducted following the principles of grounded theory. RESULTS Residents generally accepted I-PASS as an ideal format for handoffs, and valued learning a structured approach. Across all sites, residents reported full adherence to I-PASS when observed, but selective adherence in usual practice. Residents adhered more closely when patients were complex, teams were unfamiliar, and during evening handoff. Residents reported using elements of the I-PASS mnemonic variably, with Illness Severity and Action Items most consistently used, but Synthesis by Receiver least used, except when observed. Most residents were receptive to the electronic handoff tool, but perceptions about usability varied across sites. Experiences with observation and feedback were mixed. Concern about efficiency commonly influenced attitudes about I-PASS. CONCLUSIONS Residents generally supported I-PASS implementation, but adherence was influenced by patient type, context, and individual and team factors. Our findings could inform future implementation, particularly around the areas of resident engagement in change, sensitivity to resident level, perceived efficiency, and faculty observation.

Paperless handover: are we ready?

Scribbling patient information into the margins of pieces of paper during handover is a time-honoured tradition. House staff carefully guard these lists in pockets of white coats, on clipboards, or tucked into shoulder bags. They pull them out once the beeper goes off or mobile phone rings, and peer at the trusted information on the crumpled paper to guide their decision-making. ‘Patient So-and-So has a fever’, a nurse pages to inform the resident on-call, ‘Can we give something for the fever? Do you want any blood work?’ Other patients have confusion, pain or changes in their urine output. House staff record these events in check boxes, lines and circles, and read this back through bleary eyes to the incoming morning team. The scene describes a common experience for house staff using handover documents. Given the non-standardised formats and often idiosyncratic forms of documentation, it has come as no surprise that handover, (also known as handoff, sign-out, passoff or transfer of accountability) represents a common source of communication failures.1 As such, regulating bodies now mandate using structured handover processes and the teaching of handover competencies.2 ,3 Over the past decade, a substantial body of research has informed our understanding of handover processes and quality, and a recent focused effort to improve handovers produced significant reductions in preventable patient harm.4 Notwithstanding these recommendations, the ritual of printing the handover document persists. In an analysis of the use of the printed handover document at a major academic medical centre, Rosenbluth et al 5 examined its ‘half-life’, defined as the time at which half of the patients on the list would be expected to have inaccurate information present. They found that the half-life is remarkably short: only 3 h during the day and 6 h overnight. Their approach is novel and accessible, …

A single-centre hospital-wide handoff standardisation report: what is so special about that?

Healthcare leaders and scholars have articulated gaps in handoff quality across nearly all healthcare settings. A variety of drivers, including hospital accreditation, internal and external safety event analyses and medical education objectives, have given rise to a proliferation of imperatives to improve this situation. Healthcare leaders have developed a greater appreciation that handoff is a key component of a larger set of culture and teamwork strategies that are necessary to reduce harm. Researchers and medical educators have created handoff programmes, provided empirical evidence for their positive impact on safety and worked tirelessly to disseminate them.1 ,2 Quality improvers from a variety of disciplines have begun to adapt and apply standardised handoff in an increasingly diverse array of settings. In light of this, one might think it less than noteworthy to discover a report of a single institutions hospital-wide handoff standardisation programme.3 To the contrary, we find this report by Shahian et al 3 novel and rich with important messages. We agree with their assertion that this is the largest single-institution implementation of the I-PASS handoff system2 reported in a tertiary general hospital, in this case, Massachusetts General Hospital, which has 25 000 employees. Using a relatively low-cost approach, they managed to implement the system across 15 medical departments, as well as nursing, train nearly 6000 healthcare staff and collect observational data on process reliability at baseline and over 7 months of implementation. Our combined experience in multiple organisations has afforded us opportunities to understand and engage with the effort to improve handoff from multiple vantage points, including through participation as a site in the I-PASS …