New North American research shows that implementing a program to improve communication during patient handoff can effectively reduce injuries from medical errors, without complicating the workflow of busy health-care providers. The Hospital for Sick Children (SickKids) is the only participating Canadian site in the multi-centre study, published in the Nov. 5 online edition of the New England Journal of Medicine (NEJM). The residency training programs at nine children’s hospitals participated in the study, which was led by Boston Children’s Hospital.
The study involved the implementation of the I-PASS Handoff Bundle, which combines a variety of tools to improve written and verbal communication during patient handoff. Developed by the research team, this model was associated with a 23 per cent reduction in the incidence of medical errors, and a 30 per cent drop in injuries due to medical errors.
“Communication breakdown is a common cause of serious medical errors,” says Dr. Maitreya (Trey) Coffey, Medical Officer for Patient Safety, Staff Paediatrician and Project Investigator at SickKids, who is the Canadian site principal investigator for the study. “Our study shows that handoff quality improved significantly with the implementation of the I-PASS model, especially in the areas of diagnostic and communication-related errors.”
Previous studies have suggested between five and 10 per cent of hospitalized patients in Canada experience an adverse event, and about a third to half of these events may be preventable. An adverse event is harm that results from medical care rather than from the patient’s underlying condition. Serious adverse events are those that result in prolonged hospital stay, permanent disability, and even death.
With the recent trend of reducing medical residents’ work hours for safety reasons, the frequency of handoffs between residents and other health-care providers has increased. The I-PASS bundle was developed to address the patient-safety challenges resulting from this vitally important component of clinical care, and is based on existing evidence, the researchers’ experiences and the results of a previous one-site pilot study.
The program includes seven key elements:
- I-PASS mnemonic (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver), upon which all oral and written handoff processes were based
- Workshop to teach teamwork and communication skills, as well as handoff techniques
- Role-playing and simulation session
- Computer module
- Professional development program for faculty
- Direct-observation tools used by staff physicians to provide feedback to residents
- A campaign to encourage the adoption of the program and its sustainability
Between January 2011 and May 2013, outcomes were monitored at each site for six months prior to the intervention period, for six months during the implementation of the I-PASS bundle, and for six months post-intervention. All residents working on participating units received I-PASS training and were expected to use the handoff processes during their shifts. Collected data included medical errors, quality of written and oral handoffs, demographic characteristics and medical complexity for all patients on the study units. Participating units provided care for patients with varying levels of medical complexity, and none of the sites had an existing handoff program prior to the study.
Each site integrated I-PASS into oral and written handoff processes for each patient. Standardized written handoff tools were incorporated into electronic medical record programs where applicable. Each site maintained an implementation log to ensure adherence to all program components. An established surveillance process was used to measure rates of medical errors, preventable and non-preventable adverse events.
Time-motion observations were conducted during the pre-intervention and post-intervention periods to measure how much time the residents spent on activities including computer work, conducting handoffs and direct patient care. Residents also completed surveys following each shift to assess their perceptions of the handoff training.
The research team compared medical-error rates before and after the intervention period, examining 10,740 patient admissions across all nine sites. They observed a drop from 4.7 preventable adverse events per 100 admissions to 3.3 events per 100 admissions. The medical-error rate went from 24.5 to 18.8 errors per 100 admissions. As expected, there was no significant change in the rate of non-preventable adverse events (from 3.0 to 2.8 events per 100 admissions). There was no change in residents’ time spent on usual activities as a result of the implementation of the handoff model. Significant improvements were seen in residents’ communication (oral and written), and the residents reported that they were more satisfied with the quality of the handoffs.
Historically, a mandate to provide training and tools for structured, high-quality handoff has been lacking in health care. Professional bodies are currently moving toward putting stronger mandates in place to support high-quality communication between clinical staff members. Residents are also requesting handoff training as part of their curriculum.
“Handoff is a critical component of our health-care system, but for a long time, residents did not receive formal training in this area,” says Coffey, Associate Director of the Centre for Patient Safety and Associate Professor of Paediatrics at the University of Toronto. “Being able to participate in this program has helped bring the latest knowledge and most effective handoff tools to clinical teams here at SickKids and across North America.”
Following the study in which one inpatient service at each participating hospital implemented I-PASS, the program is now being implemented, or adapted where needed, to meet the unique needs of the diverse array of medical specialties across SickKids. Handoff programs are currently in place in about half the hospital’s inpatient units, including Paediatric Medicine and Cardiology.
The I-PASS Handoff Bundle is available, free of charge, at www.ipasshandoffstudy.com.
Co-collaborators were Benioff Children’s Hospital, Cincinnati Children’s Hospital Medical Center, Doernbecher Children’s Hospital, Lucile Packard Children’s Hospital, Primary Children’s Hospital, St. Louis Children’s Hospital, St. Christopher’s Hospital for Children and Walter Reed National Military Medical Center.
The research was funded by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, the Medical Research Foundation of Oregon, Physician Services Incorporated Foundation and Pfizer, the Initiative for Innovation in Pediatric Education and the Pediatric Research in Inpatient Settings Network, and SickKids Foundation.
About The Hospital for Sick Children
The Hospital for Sick Children (SickKids) is recognized as one of the world’s foremost paediatric health-care institutions and is Canada’s leading centre dedicated to advancing children’s health through the integration of patient care, research and education. Founded in 1875 and affiliated with the University of Toronto, SickKids is one of Canada’s most research-intensive hospitals and has generated discoveries that have helped children globally. Its mission is to provide the best in complex and specialized family-centred care; pioneer scientific and clinical advancements; share expertise; foster an academic environment that nurtures health-care professionals; and champion an accessible, comprehensive and sustainable child health system. SickKids is proud of its vision for Healthier Children. A Better World. For more information, please visit www.sickkids.ca.
For more information, please contact:
The Hospital for Sick Children
416-813-7654, ext. 202059
The Hospital for Sick Children