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Authors
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Project Leader for I-PASS Study, Director of Primary Care Quality Improvement at Boston Children's HospitalAmy Starmer, MD, MPH
Project Leader for I-PASS Study, Director of Primary Care Quality Improvement at Boston Children's HospitalProject Leader for I-PASS Study, Director of Primary Care Quality Improvement at Boston Children's Hospital
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Chair of the I-PASS Executive Council, PD at St. Christopher’s Hospital for ChildrenNancy Spector, MD
Chair of the I-PASS Executive Council, PD at St. Christopher’s Hospital for ChildrenChair of the I-PASS Executive Council, PD at St. Christopher’s Hospital for Children
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Assistant Vice President of Research at Intermountain HealthcareRaj Srivastava, MD, FRCP, MPH
Assistant Vice President of Research at Intermountain HealthcareAssistant Vice President of Research at Intermountain Healthcare
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I-PASS Institute Executive Council Member, Director of the Pediatric Residency Program at UCSFDaniel West, MD
I-PASS Institute Executive Council Member, Director of the Pediatric Residency Program at UCSFI-PASS Institute Executive Council Member, Director of the Pediatric Residency Program at UCSF
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Associate Director of the Pediatrics Residency Program at the Benioff Children’s HospitalGlenn Rosenbluth, MD
Associate Director of the Pediatrics Residency Program at the Benioff Children’s HospitalAssociate Director of the Pediatrics Residency Program at the Benioff Children’s Hospital
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Hospitalist at Brigham and Women's Hospital, Site PI for IPASS Data Coordinating CenterAnuj Dalal, MD
Hospitalist at Brigham and Women's Hospital, Site PI for IPASS Data Coordinating CenterHospitalist at Brigham and Women's Hospital, Site PI for IPASS Data Coordinating Center
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Assistant VP for CRICO/RMF’s Academic Medical Center Patient Safety OrganizationCarol Keohane, MS, RN
Assistant VP for CRICO/RMF’s Academic Medical Center Patient Safety OrganizationAssistant VP for CRICO/RMF’s Academic Medical Center Patient Safety Organization
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Site PI for Cincinnati Children's Hospital in the I-PASS InstituteJennifer O'Toole, MD, MEd
Site PI for Cincinnati Children's Hospital in the I-PASS InstituteSite PI for Cincinnati Children's Hospital in the I-PASS Institute
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i-PASS PI, Assistant Professor of Pediatrics at Oregon Health & Science University School of MedicineMegan Aylor, MD
i-PASS PI, Assistant Professor of Pediatrics at Oregon Health & Science University School of Medicinei-PASS PI, Assistant Professor of Pediatrics at Oregon Health & Science University School of Medicine
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Assistant Professor of Dept of Paediatrics of U. of TorontoZia Bismilla, MD, FRCPC, MEd
Assistant Professor of Dept of Paediatrics of U. of TorontoAssistant Professor of Dept of Paediatrics of U. of Toronto
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Executive Member of PIPSQC, Medical Officer for Patient Safety at SickKidsMaitreya (Trey) Coffey, MD, FRCPC
Executive Member of PIPSQC, Medical Officer for Patient Safety at SickKidsExecutive Member of PIPSQC, Medical Officer for Patient Safety at SickKids
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Associate Program Director of the General Paediatrics Fellowship at The Hospital for Sick ChildrenSanjay Mahant, MD, MSc, FRCPC
Associate Program Director of the General Paediatrics Fellowship at The Hospital for Sick ChildrenAssociate Program Director of the General Paediatrics Fellowship at The Hospital for Sick Children
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I-PASS Co-Investigator at Stanford, Clinical Assistant Professor StanfordLauren Destino, MD
I-PASS Co-Investigator at Stanford, Clinical Assistant Professor StanfordI-PASS Co-Investigator at Stanford, Clinical Assistant Professor Stanford
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Vice Chair-Education of Pediatrics at the University of Utah Health CareJames Bale, Jr, MD
Vice Chair-Education of Pediatrics at the University of Utah Health CareVice Chair-Education of Pediatrics at the University of Utah Health Care
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Educational Executive Committee Member on the I-PASS studySharon Calaman, MD, CHSE
Educational Executive Committee Member on the I-PASS studyEducational Executive Committee Member on the I-PASS study
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Neonatologist at Washington University School of Medicine and St. Louis Children's HospitalF Sessions Cole, MD
Neonatologist at Washington University School of Medicine and St. Louis Children's HospitalNeonatologist at Washington University School of Medicine and St. Louis Children's Hospital
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Assistant Prof of Pediatrics at the USU, Co-Principal Investigator at NCC of I-PASSJennifer Hepps, MD
Assistant Prof of Pediatrics at the USU, Co-Principal Investigator at NCC of I-PASSAssistant Prof of Pediatrics at the USU, Co-Principal Investigator at NCC of I-PASS
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Associate Dean for Simulation Education at the Uniformed Services UniversityJoseph Lopreiato, MD, MPH
Associate Dean for Simulation Education at the Uniformed Services UniversityAssociate Dean for Simulation Education at the Uniformed Services University
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Director of Graduate Medical Education at Walter Reed Military Medical CenterClifton Yu, MD, FAAP
Director of Graduate Medical Education at Walter Reed Military Medical CenterDirector of Graduate Medical Education at Walter Reed Military Medical Center
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I-PASS Executive Council, Program Director at BCHTheodore Sectish, MD
I-PASS Executive Council, Program Director at BCHI-PASS Executive Council, Program Director at BCH
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Professor of Pediatrics, Hospitalist, and Patient Safety Researcher at Boston Children’s Hospital, Brigham and Women's Hospital, Harvard Medical SchoolChristopher Landrigan, MD, MPH
Professor of Pediatrics, Hospitalist, and Patient Safety Researcher at Boston Children’s Hospital, Brigham and Women's Hospital, Harvard Medical SchoolProfessor of Pediatrics, Hospitalist, and Patient Safety Researcher at Boston Children’s Hospital, Brigham and Women's Hospital, Harvard Medical School
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Experts
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Director of the Armstrong Institute for Patient Safety & Quality at Johns HopkinsPeter Pronovost, MD, PhD, FCCM
Director of the Armstrong Institute for Patient Safety & Quality at Johns HopkinsDirector of the Armstrong Institute for Patient Safety & Quality at Johns Hopkins
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Chief Medical & Scientific Officer of the Institute for Healthcare ImprovementDonald Goldmann, MD
Chief Medical & Scientific Officer of the Institute for Healthcare ImprovementChief Medical & Scientific Officer of the Institute for Healthcare Improvement
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Director of Medical Education Outcomes & Research at UABLee Ann Riesenberg, RN, BS, MS, PhD
Director of Medical Education Outcomes & Research at UABDirector of Medical Education Outcomes & Research at UAB
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Medical & Scientific Advisory Board Member of Global GenesAyesha Khalid, MD, MBA
Medical & Scientific Advisory Board Member of Global GenesMedical & Scientific Advisory Board Member of Global Genes
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Moderators
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General Internist, Massachusetts General Hospital, Research Fellow, Brigham and Women's HospitalChana Sacks, MD
General Internist, Massachusetts General Hospital, Research Fellow, Brigham and Women's HospitalGeneral Internist, Massachusetts General Hospital, Research Fellow, Brigham and Women's Hospital
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Pediatric Urology Fellow at Boston Children's HospitalRena Xu, MD, MBA
Pediatric Urology Fellow at Boston Children's HospitalPediatric Urology Fellow at Boston Children's Hospital
About the Discussion
@NEJM Ask the Authors: Changes in Medical Errors after Implementation of a Handoff Program
VIDEO INTRODUCTION
F. Sessions Cole, MD
Park J. White, M.D. Professor of Pediatrics
Washington University School of Medicine in St. Louis
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). Sitelevel 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.)
Click Here to Read the Full Article on NEJM.orgVIDEOS BY THE STUDY AUTHORS
Amy Starmer, MD, MPH
Project Leader for I-PASS Study
Director of Primary Care Quality Improvement at Boston Children's Hospital
Christopher Landrigan, MD, MPH
Principal Investigator of I-PASS
Director of the Inpatient Pediatrics Service at Boston Children’s Hospital
Nancy Spector, MD
Chair of the I-PASS Executive Council
PD at St. Christopher’s Hospital for Children
Theodore Sectish, MD
I-PASS Executive Council
Program Director at Boston Children's Hospital
Daniel West, MD
I-PASS Institute Executive Council Member
Director of the Pediatric Residency Program at UCSF
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Authors
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Project Leader for I-PASS Study, Director of Primary Care Quality Improvement at Boston Children's HospitalAmy Starmer, MD, MPH
Project Leader for I-PASS Study, Director of Primary Care Quality Improvement at Boston Children's Hospital
Project Leader for I-PASS Study, Director of Primary Care Quality Improvement at Boston Children's Hospital
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Chair of the I-PASS Executive Council, PD at St. Christopher’s Hospital for ChildrenNancy Spector, MD
Chair of the I-PASS Executive Council, PD at St. Christopher’s Hospital for Children
Chair of the I-PASS Executive Council, PD at St. Christopher’s Hospital for Children
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Assistant Vice President of Research at Intermountain HealthcareRaj Srivastava, MD, FRCP, MPH
Assistant Vice President of Research at Intermountain Healthcare
Assistant Vice President of Research at Intermountain Healthcare
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I-PASS Institute Executive Council Member, Director of the Pediatric Residency Program at UCSFDaniel West, MD
I-PASS Institute Executive Council Member, Director of the Pediatric Residency Program at UCSF
I-PASS Institute Executive Council Member, Director of the Pediatric Residency Program at UCSF
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Associate Director of the Pediatrics Residency Program at the Benioff Children’s HospitalGlenn Rosenbluth, MD
Associate Director of the Pediatrics Residency Program at the Benioff Children’s Hospital
Associate Director of the Pediatrics Residency Program at the Benioff Children’s Hospital
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Hospitalist at Brigham and Women's Hospital, Site PI for IPASS Data Coordinating CenterAnuj Dalal, MD
Hospitalist at Brigham and Women's Hospital, Site PI for IPASS Data Coordinating Center
Hospitalist at Brigham and Women's Hospital, Site PI for IPASS Data Coordinating Center
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Assistant VP for CRICO/RMF’s Academic Medical Center Patient Safety OrganizationCarol Keohane, MS, RN
Assistant VP for CRICO/RMF’s Academic Medical Center Patient Safety Organization
Assistant VP for CRICO/RMF’s Academic Medical Center Patient Safety Organization
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Site PI for Cincinnati Children's Hospital in the I-PASS InstituteJennifer O'Toole, MD, MEd
Site PI for Cincinnati Children's Hospital in the I-PASS Institute
Site PI for Cincinnati Children's Hospital in the I-PASS Institute
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i-PASS PI, Assistant Professor of Pediatrics at Oregon Health & Science University School of MedicineMegan Aylor, MD
i-PASS PI, Assistant Professor of Pediatrics at Oregon Health & Science University School of Medicine
i-PASS PI, Assistant Professor of Pediatrics at Oregon Health & Science University School of Medicine
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Assistant Professor of Dept of Paediatrics of U. of TorontoZia Bismilla, MD, FRCPC, MEd
Assistant Professor of Dept of Paediatrics of U. of Toronto
Assistant Professor of Dept of Paediatrics of U. of Toronto
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Executive Member of PIPSQC, Medical Officer for Patient Safety at SickKidsMaitreya (Trey) Coffey, MD, FRCPC
Executive Member of PIPSQC, Medical Officer for Patient Safety at SickKids
Executive Member of PIPSQC, Medical Officer for Patient Safety at SickKids
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Associate Program Director of the General Paediatrics Fellowship at The Hospital for Sick ChildrenSanjay Mahant, MD, MSc, FRCPC
Associate Program Director of the General Paediatrics Fellowship at The Hospital for Sick Children
Associate Program Director of the General Paediatrics Fellowship at The Hospital for Sick Children
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I-PASS Co-Investigator at Stanford, Clinical Assistant Professor StanfordLauren Destino, MD
I-PASS Co-Investigator at Stanford, Clinical Assistant Professor Stanford
I-PASS Co-Investigator at Stanford, Clinical Assistant Professor Stanford
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Vice Chair-Education of Pediatrics at the University of Utah Health CareJames Bale, Jr, MD
Vice Chair-Education of Pediatrics at the University of Utah Health Care
Vice Chair-Education of Pediatrics at the University of Utah Health Care
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Educational Executive Committee Member on the I-PASS studySharon Calaman, MD, CHSE
Educational Executive Committee Member on the I-PASS study
Educational Executive Committee Member on the I-PASS study
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Neonatologist at Washington University School of Medicine and St. Louis Children's HospitalF Sessions Cole, MD
Neonatologist at Washington University School of Medicine and St. Louis Children's Hospital
Neonatologist at Washington University School of Medicine and St. Louis Children's Hospital
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Assistant Prof of Pediatrics at the USU, Co-Principal Investigator at NCC of I-PASSJennifer Hepps, MD
Assistant Prof of Pediatrics at the USU, Co-Principal Investigator at NCC of I-PASS
Assistant Prof of Pediatrics at the USU, Co-Principal Investigator at NCC of I-PASS
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Associate Dean for Simulation Education at the Uniformed Services UniversityJoseph Lopreiato, MD, MPH
Associate Dean for Simulation Education at the Uniformed Services University
Associate Dean for Simulation Education at the Uniformed Services University
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Director of Graduate Medical Education at Walter Reed Military Medical CenterClifton Yu, MD, FAAP
Director of Graduate Medical Education at Walter Reed Military Medical Center
Director of Graduate Medical Education at Walter Reed Military Medical Center
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I-PASS Executive Council, Program Director at BCHTheodore Sectish, MD
I-PASS Executive Council, Program Director at BCH
I-PASS Executive Council, Program Director at BCH
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Professor of Pediatrics, Hospitalist, and Patient Safety Researcher at Boston Children’s Hospital, Brigham and Women's Hospital, Harvard Medical SchoolChristopher Landrigan, MD, MPH
Professor of Pediatrics, Hospitalist, and Patient Safety Researcher at Boston Children’s Hospital, Brigham and Women's Hospital, Harvard Medical School
Professor of Pediatrics, Hospitalist, and Patient Safety Researcher at Boston Children’s Hospital, Brigham and Women's Hospital, Harvard Medical School
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Experts
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Director of the Armstrong Institute for Patient Safety & Quality at Johns HopkinsPeter Pronovost, MD, PhD, FCCM
Director of the Armstrong Institute for Patient Safety & Quality at Johns Hopkins
Director of the Armstrong Institute for Patient Safety & Quality at Johns Hopkins
-
Chief Medical & Scientific Officer of the Institute for Healthcare ImprovementDonald Goldmann, MD
Chief Medical & Scientific Officer of the Institute for Healthcare Improvement
Chief Medical & Scientific Officer of the Institute for Healthcare Improvement
-
Director of Medical Education Outcomes & Research at UABLee Ann Riesenberg, RN, BS, MS, PhD
Director of Medical Education Outcomes & Research at UAB
Director of Medical Education Outcomes & Research at UAB
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Medical & Scientific Advisory Board Member of Global GenesAyesha Khalid, MD, MBA
Medical & Scientific Advisory Board Member of Global Genes
Medical & Scientific Advisory Board Member of Global Genes
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Moderators
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General Internist, Massachusetts General Hospital, Research Fellow, Brigham and Women's HospitalChana Sacks, MD
General Internist, Massachusetts General Hospital, Research Fellow, Brigham and Women's Hospital
General Internist, Massachusetts General Hospital, Research Fellow, Brigham and Women's Hospital
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Pediatric Urology Fellow at Boston Children's HospitalRena Xu, MD, MBA
Pediatric Urology Fellow at Boston Children's Hospital
Pediatric Urology Fellow at Boston Children's Hospital
