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Improved handoff communication key to preventing errors

Better implementation of handoff programs might be needed to reduce medical errors at hospitals and other healthcare facilities, a New England Journal of Medicine study stated.

The study, released Nov. 6, said use of a handoff improvement program at nine pediatric hospitals in the U.S. and Canada played a role in lowering medical errors and adverse events.

Researchers analyzed 10,740 patient admissions, showing the medical error rate decreased 23% from the period before the program was implemented to after improved handoff measures were in place. Preventable adverse events decreased by 30%, according to the study.

On-site analysis showed major decreases in medical errors at six of the nine facilities, the study said. Noticeable increases were found in key elements such as written documents and oral communication during handoff. Training for the program included using I-PASS, a medical education curriculum and mnemonic device that serves as a checklist during handoffs. The acronym stands for Illness severity, Patient summary, Action list for the next team, Situation awareness/contingency plans and Synthesis. Training also included a two-hour workshop on teamwork and communication and The 900 residents trained in the program also attended a workshop on teamwork and communication, role playing and a computer module for independent learning.

All healthcare providers are required by the Joint Commission to “implement a standardized approach to handoff communications including an opportunity to ask and respond to questions,” according to the commission’s National Patient Safety Goal. The National Patient Safety Goal’s guidelines for the handoff process include interactive communications, up-to-date and accurate information, limited interruptions, a process for verification and an opportunity to review any relevant historical data.

Researchers pointed to miscommunication as a leading cause of medical errors. During the assessment period of the nine facilities, no significant change was found in the duration of oral handoffs, minutes per patient or in resident workflow, including patient-family contact and computer time, the study stated.

“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,” the researchers concluded.

To read the full study, visit

By | 2014-11-19T00:00:00-05:00 November 19th, 2014|Categories: National|0 Comments

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