Safer Patient Handoffs - Blog

Retrospective Study Shows 30-Day Surgical Outcomes Were No Worse After Implementation of 2011 ACGME Resident Work Hour Restrictions

July 10, 2015

A new retrospective study that is the subject of an "in press" article that is to appear in the Journal of the American College of Surgeons later this year shows that the 2011 ACGME work hour restrictions did not adversely impact 30-day surgical outcomes. [Read More]

Which Would You Prefer...A Tired Doc That Knows Your Case, Or A Rested Doc That Does Not?

July 4, 2015

Regulations in the United States have limited the work hours that newly minted physicians, called interns, and physicians in training, called residents, can work in the hospital. The work hour restrictions were ushered in based on evidence that sleep deprived physicians make more errors (i.e. medication errors, diagnostic errors, serious errors with critically ill patients, etc.) and score lower on simple cognition tests including response time, reasoning, recall, and concentration. However, inextricably tied to this reduction in the work hours for physicians in training is the need for more handoffs...

Distractions During Ambulatory Surgery Center Patient Handoffs May Put Patients At Risk

July 2015

New research published in the Clinical Anesthesiology section of the July 2015 edition of Anesthesiology News finds that when patient handoff communications in ambulatory surgery centers (ASCs) are interrupted, they are associated with more errors. The investigators also estimate that some 50 percent of the interruptions observed might have been avoidable. [Read More]

Three Steps | Improving Patient Handoffs

June 27, 2015

Handoffs, also called 'handovers,' 'signouts,' or 'report,' are key to patient safety as communication errors at the time of care transitions are a significant source of medical errors. So how can healthcare provider organizations improve handoffs at transitions in patient care?

The EMS to Hospital Handoff: Getting It Right

June 19, 2015

On a daily basis, EMS technicians transport numerous patients to US hospitals. The end of every such transport episode is a handoff to the hospital staff that will be assuming care of the patient being transported. In a recent podcast, Inside EMS hosts, Chris Cebollero and Kelly Grayson, discuss some of the common challenges encountered and the importance of detailing to the hospital staff the response the patient had to interventions undertaken by EMS.

Handoff Advice For Interns: Practice Makes Perfect

Brigham and Women's Hospital

June 18, 2015

An internal medicine resident wrapping up her 1st year of residency at Brigham and Women’s Hospital put together a piece summarizing her advice for incoming internal medicine interns. Her thoughts: “Handoffs and transitions of care are two of the most important things we do, and we do a lot of them. Practice giving and receiving feedback and learning how to improve these skills…” Read more about her other recommendations here

The Perils Of Un-Safe Signouts: What Happens When Physicians Fail To Communicate

June 16, 2015

In a recent piece that appeared in the New York Times (NYT) on June 18, 2015, a Massachusetts General internal medicine resident shares some of her experiences in the hospital that illustrate what can happen when physicians fail to communicate with each other. It has been well documented that poorly executed, non-standardized patient handoffs and signouts are linked to preventable medical errors and adverse events. In fact...

The Role Of Pharmacists In Medical Error Prevention At Care Transitions

Pharmacy Times

June 13, 2015

According to Pharmacy Times, pharmacy faculty at the Lloyd L. Gregory School of Pharmacy recently enumerated the most common causes of medication errors during transitions in care and the role the pharmacist can play in preventing them. The researchers reported that in the majority of cases poor communication between care team members is the root cause of the errors; they also report that pharmacists can help combat errors by conducting medication reconciliation across the care continuum at the time of transitions between various care settings.

Standardization with a Checklist May Improve Information Exchange In OR to PACU Handoffs

June 2015

A recent study appearing in the June 2015 edition of the Journal of the Anesthesia Patient Safety Foundation reported the findings of a small study examining operating room (OR) to post anesthesia care unit (PACU) handoffs, specifically handoffs from anesthesia residents to PACU nurses. The authors examined the impact of a checklist intervention on the exchange of information and the amount of time required for the handoff communication...

Use of a Standardized Handover Template In General Surgery Improves The Quality of Information on Handoff Reports

May 25, 2015

A recent study appearing in the Journal of Patient Safety on May 21, 2015 examined the impact of having the general surgery department of a hospital in the United Kingdom utilize a standardized form for sign outs between surgeons coming on and off duty. In the study, a baseline assessment of surgical handoff or handover reports was conducted. After this baseline assessment, a new standardized handoff form developed in accordance with guidelines for handovers from the Royal College of Surgeons was introduced. The authors state the forms were circulated among the department members and were made readily available on the wards. Six weeks after this intervention...

Bedside Hand-Off Reporting: A Strategy To Improve Patient Care and Patient Satisfaction

Oncology Nurse Advisor

April 24, 2015

After implementing bedside hand-off reporting, Nurses from Cancer Treatment Centers of America found their staff reported not only increased handoff communication and professional practice, but also that patients felt more informed about their care and were proponents of the practice…

Do ‘Face-To-Face’ Handoffs Make Sign Out Safer?

March 29 2015

Recent research published in the Journal of Hospital Medicine in March, 2015 found that ‘face-to-face’ handoffs between internal medicine providers at a tertiary care academic medical center had no impact on the rate of medical codes, deaths or hospital readmissions. However, other researchers point out the study was i) not adequately powered to detect a difference if one existed; and ii) retrospective and thus cannot establish a true cause and effect relationship. So are ‘face-to-face’ handoffs safer than those not done in-person?

Can Tracking Handoff Completion Rates Improve Patient Safety?

Hospital Pediatrics

March 1, 2015

A recent study appearing in Hospital Pediatrics examined the impact of implementing handoff document standardization, handoff training, and the identification and mitigation of handoff failures. The authors report that the interventions improved verbal handoff completion rates from 76% to 100% and that the improvement was sustained for 15 months. An interesting aspect of the study was the investigator’s use of statistical control charts to follow handoff completions…

Implementing Standardized Handoff Communications in an NHS PICU Setting

Pediatric International Patient Safety and Quality Community

December 16, 2014

In December 2014 Pediatric International Patient Safety and Quality Community (PIPSQC) blog posting, an NHS PICU describes and shares their early findings from the implementation of a handoff training program that involved standardizing handoff communications between healthcare providers. The PICU implemented the IPASS handoff program, including the IPASS handoff report format and verbal presentation format. The authors report that the program added ‘structure to the handover, improving consistency of delivery and reducing interruptions to the flow of the patient’s “story”’ and state that on a post implementation survey 78% of respondents rated the IPASS ward rounding format as an improvement.

New Research Says Standardizing Handoff Communications In Medicine Makes Patient Signouts Safer

December 14, 2014

A report of the findings from a prospective study appearing in the Journal of the American Medical Association (JAMA) on December 13, 2014, found that standardizing handoff communications can significantly reduce the rate of preventable medical errors in the pediatric inpatient academic medical setting. The authors report their findings from the study, which was carried out in 2009 and 2010 on two inpatient units at Boston Children’s Hospital. In the study, an intervention, dubbed ‘I-PASS’ was implemented via...

So Standardized Sign-Outs Improve Patient Safety, But Do They Make Patient Handoffs Take Longer?

Contrary to a common sentiment (and oft-reality) in medicine that new change will make existing processes take longer, researchers have proven that the time it takes to do standardized handoffs actually takes…[read more]

What Is The I-PASS Resident Handoff Bundle and Why Can It Save Patient Lives

November 22, 2015

The specific numbers vary, but medical errors are estimated to kill hundreds of thousands of Americans in US hospitals every year. However, the large majority of these errors and the deaths they cause are preventable. In November 2014, researchers from several prominent US academic medical centers shared their findings from a large, prospective, multi-center, research trial that investigated an intervention that standardized handoff communications between inpatient pediatric medical providers coming on and off duty. The intervention was found to significantly reduced medical errors. One of the key components of the intervention was something the researchers call a Resident Training Bundle or IPASS Training Bundle. So what exactly is a resident handoff bundle…