Boston Children's devises handoff procedures to reduce errors and improve patient safety

In 2009, clinician-researchers at Boston Children's Hospital were alarmed by national data suggesting a strong link between poor communication and errors. As many as 70% of medical errors and subsequent adverse events can be traced to poor communication, safety experts say, and many of those communication lapses occur when transferring patients between care providers.

The researchers saw that medical interns and senior resident physicians at the hospital were doing their patient handoffs at each shift change in separate rooms, leaving interns without the benefit of much-needed supervision.

Improving patient handoffs is a tough task because hospital care is fast-paced and complex, patient acuity is increasing and busy clinicians convey patient information to one another in vastly different ways, said Mary Ann Friesen, nursing research coordinator at Inova Health System, Falls Church, Va., whose own work focuses on patient-centered approaches to handoffs. “It's not just a matter of delivering a message,” she said. “The (other) person has to receive it.”

So the team at Boston Children's developed a program to standardize handoffs and protect against haphazard lapses that could lead to safety events and patient harm. And they developed a handy mnemonic device, called I-PASS, for helping providers effectively hand off patients to each other at shift changes.

I-PASS stands for illness severity; patient summary; action list; situation awareness and contingency planning; and synthesis or read-back. It provides a structure for residents to quickly and efficiently brief each other on patient information, said Dr. Christopher Landrigan, director of Boston Children's inpatient program and lead investigator of a recently completed multicenter study that rolled out the I-PASS intervention in 10 academic medical centers across the U.S. and Canada.

The I-PASS mnemonic is just one component in a bundle of handoff interventions, including specialized training and a written handout, instituted at the 395-bed hospital.

The risks associated with inadequate handoffs have grown in recent years, as resident work-hour limits took effect and the frequency of such caregiver-to-caregiver transitions has increased.

In addition to the I-PASS mnemonic, Boston Children's handoff bundle includes a computerized handoff tool, embedded in the electronic health record, which automatically fills in patient data. The intervention also features two hours of educational training for participating clinicians.

Landrigan and his colleagues also relocated patient handoffs to a quiet conference room where all resident physicians and interns conduct patient handoffs as a team.

Senior residents initially worried that watching over handoffs between interns would interrupt their workflow, said Dr. Bradley Podd, a chief resident at Boston Children's. “That turned out not to be the case at all,” he said. “The entire team was sharing information and it worked very well.”

The earliest version of Boston Children's handoff bundle, implemented over three months in late 2009 and early 2010, led to a 40% drop in overall medical errors—from 33.8 per 100 admissions to 18.3 per 100 admissions—and a 50% reduction in errors that cause patient harm—from 3.3 per 100 admissions to 1.5 per 100 admissions—compared with an earlier baseline measurement period. That study's results, which included 1,255 patients, appeared in the Dec. 4, 2013 issue of the Journal of the American Medical Association.

Galvanized by those results, Landrigan and a team of researchers used the pilot as groundwork for an I-PASS study, which implemented a refined version of the handoff bundle at Boston Children's and nine other hospitals. Those results are expected this summer.

Friesen praised interventions such as the one at Boston Children's that introduces a uniform but customizable way to communicate information every time. “That structure is very important because it helps people organize their thoughts and helps them to see anything they might have missed,” she said.

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