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Project Leader for I-PASS Study, Director of Primary Care Quality Improvement at Boston Children's Hospital
Chair of the I-PASS Executive Council, PD at St. Christopher’s Hospital for Children
Assistant Vice President of Research at Intermountain Healthcare
I-PASS Institute Executive Council Member, Director of the Pediatric Residency Program at UCSF
Associate Director of the Pediatrics Residency Program at the Benioff Children’s Hospital
Hospitalist at Brigham and Women's Hospital, Site PI for IPASS Data Coordinating Center
Assistant VP for CRICO/RMF’s Academic Medical Center Patient Safety Organization
Site PI for Cincinnati Children's Hospital in the I-PASS Institute
i-PASS PI, Assistant Professor of Pediatrics at Oregon Health & Science University School of Medicine
Assistant Professor of Dept of Paediatrics of U. of Toronto
Executive Member of PIPSQC, Medical Officer for Patient Safety at SickKids
Associate Program Director of the General Paediatrics Fellowship at The Hospital for Sick Children
I-PASS Co-Investigator at Stanford, Clinical Assistant Professor Stanford
Vice Chair-Education of Pediatrics at the University of Utah Health Care
Educational Executive Committee Member on the I-PASS study
CMO of St. Louis Children's Hospital, Chief of the Division of Newborn Medicine
Assistant Prof of Pediatrics at the USU, Co-Principal Investigator at NCC of I-PASS
Associate Dean for Simulation Education at the Uniformed Services University
Director of Graduate Medical Education at Walter Reed Military Medical Center
I-PASS Executive Council, Program Director at BCH
Professor of Pediatrics, Hospitalist, and Patient Safety Researcher at Boston Children’s Hospital, Brigham and Women's Hospital, Harvard Medical School
Director of the Armstrong Institute for Patient Safety & Quality at Johns Hopkins
Chief Medical & Scientific Officer of the Institute for Healthcare Improvement
Director of Medical Education Outcomes & Research at UAB
Medical & Scientific Advisory Board Member of Global Genes
General Internist, Massachusetts General Hospital, Research Fellow, Brigham and Women's Hospital
Resident Physician at Massachusetts General Hospital
F. Sessions Cole, MD
Park J. White, M.D. Professor of Pediatrics
Washington University School of Medicine in St. Louis
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.
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.
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.
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.orgAmy 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
Project Leader for I-PASS Study, Director of Primary Care Quality Improvement at Boston Children's Hospital
Chair of the I-PASS Executive Council, PD at St. Christopher’s Hospital for Children
Assistant Vice President of Research at Intermountain Healthcare
I-PASS Institute Executive Council Member, Director of the Pediatric Residency Program at UCSF
Associate Director of the Pediatrics Residency Program at the Benioff Children’s Hospital
Hospitalist at Brigham and Women's Hospital, Site PI for IPASS Data Coordinating Center
Assistant VP for CRICO/RMF’s Academic Medical Center Patient Safety Organization
Site PI for Cincinnati Children's Hospital in the I-PASS Institute
i-PASS PI, Assistant Professor of Pediatrics at Oregon Health & Science University School of Medicine
Assistant Professor of Dept of Paediatrics of U. of Toronto
Executive Member of PIPSQC, Medical Officer for Patient Safety at SickKids
Associate Program Director of the General Paediatrics Fellowship at The Hospital for Sick Children
I-PASS Co-Investigator at Stanford, Clinical Assistant Professor Stanford
Vice Chair-Education of Pediatrics at the University of Utah Health Care
Educational Executive Committee Member on the I-PASS study
CMO of St. Louis Children's Hospital, Chief of the Division of Newborn Medicine
Assistant Prof of Pediatrics at the USU, Co-Principal Investigator at NCC of I-PASS
Associate Dean for Simulation Education at the Uniformed Services University
Director of Graduate Medical Education at Walter Reed Military Medical Center
I-PASS Executive Council, Program Director at BCH
Professor of Pediatrics, Hospitalist, and Patient Safety Researcher at Boston Children’s Hospital, Brigham and Women's Hospital, Harvard Medical School
Director of the Armstrong Institute for Patient Safety & Quality at Johns Hopkins
Chief Medical & Scientific Officer of the Institute for Healthcare Improvement
Director of Medical Education Outcomes & Research at UAB
Medical & Scientific Advisory Board Member of Global Genes
General Internist, Massachusetts General Hospital, Research Fellow, Brigham and Women's Hospital
Resident Physician at Massachusetts General Hospital