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.