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Andrea Dicus, CNIII, Intermediate Surgical Care Unit (ISCU), is co-chair of the Nursing Handoffs and Transitions Task Force, which recommends using of a new standardized handoff tool to create safer patient handoffs at shift changes. ISCU nurses conduct a patient-engaged report as part of the new handoff procedures on their unit. It became the taskforcea€™s mission to understand the critical elements of a thorough handoff and to review and understand the current processes across units during handoffs; identifying both things that work well and areas of needed improvement.
Serving as a trial for improved handoffs, Andrea and the leadership team in the ISCU has implemented the standardized handoff tool designed by the Handoff and Transitions Taskforce on their unit.
The intent is to provide all relevant information that the oncoming nurse will need to properly care for the patient. In addition to filling out the tool, ISCU nurses also present the completed tool to the oncoming nurse in front of the patient. Andrea believes that the results of including patients in their care will be seen on future patient satisfaction scores.
Andrea points out that the benefits of a standardized shift change are felt in other important areas.
Andrea and the task force hope that shift change standardization will become a hospital-wide effort. Always Event(s): Patients will always be included in the ISHAPED handoff shift-to-shift hand-off process at the bedside as this will add an additional layer of safety by allowing the patient to communicate potential safety concerns.
Overview: This project will build on previous research by the Inova Health System (IHS) to improve the quality and safety of patient care by enhancing communication and encouraging patient participation. It was the beginning of an overnight shift, and the junior resident was the only one in house. For residents, knowing how to communicate crucial handoff details is a skill learned on the job. Improvements in oral and written communication between health care providers during patient handoffs can reduce injuries due to medical errors by 30 percent, according to a multicenter study led by Harvard Medical School researchers at Boston Children’s Hospital. Medical errors in hospitals such as diagnostic delays, preventable surgical complications and medication overdoses are a leading cause of death and injury in the United States.
A multicenter team led by Landrigan and the study’s lead author, Amy Starmer, HMS lecturer on pediatrics at Boston Children’s, designed I-PASS with the goal of improving patient safety and reducing or eliminating the most common source of medical errors through improved provider-to-provider communication.
In the NEJM paper, Landrigan, Starmer and their colleagues report on the results of implementing I-PASS through the pediatric residency programs of nine hospitals. At each participating hospital, patient handoffs by residents were monitored and assessed for a six-month pre-intervention period.
Time-motion analyses of providers’ activities showed that implementing I-PASS did not add time to patient handoffs or decrease time spent at patient bedsides or on other tasks. Landrigan and Starmer note that while the I-PASS bundle has been focused thus far on inpatient pediatric care, the principles are applicable to care in any hospital inpatient setting. To enhance patient safety, many institutions have made improving patient handoffs a priority but research on the interventions used to attain this goal has been limited to single-center studies. In addition, significant decreases were seen in rates of specific types of medical errors, including diagnostic errors.
The findings build on those from single-institution studies showing that handoff-improvement programs can improve patient safety, but an important strength of this analysis is that it was effective at multiple study sites. A new study from Boston Children’s Hospital’s division of general paediatrics — published by the Journal of the American Medical Association (JAMA) — indicates that improving verbal and written communication during patient handoffs can reduce medical errors substantially without burdening existing workflows. Medical errors are a leading cause of death and injury in the US, with an estimated 80 per cent of serious medical errors involving some form of miscommunication, particularly when care is transferred in a hospital setting from one provider to the next. Error types included those with little or no potential for harm, intercepted potential adverse events, non-intercepted potential adverse events and preventable adverse events. With the goal of improving provider-to-provider communication, Dr Landrigan and Dr Amy Starmer, lead author of the study, designed a multi-faceted, bundled handoff system consisting of three key components: standardized communication and handoff training, a verbal mnemonic and a new team handoff structure.
The researchers examined 1,255 patient admissions that occurred during the implementation of the handoff bundle to measure how it impacted patient care and clinician workflow across two separate inpatient units at Boston Children’s.
Implementation of the new system began with an interactive workshop for all participating clinicians, during which they practiced giving and receiving handoffs under different clinical and real-world scenarios.
Secondly, participants adopted an easy-to-remember mnemonic to ensure all relevant information was verbally communicated during the handoff. Finally, in conjunction with Boston Children’s informatics team, the researchers created a structured handoff tool within the electronic medical record (EMR) to standardize the documentation of patient information that is transmitted at change of shift. After implementation of the communication bundle there were fewer omissions or miscommunications about important data during handoffs, which led to positive results.
Based on the results of this study, Dr Landrigan and team developed I-PASS, a handoff bundle rolling out to 10 teaching hospitals across North America.
Health A-Z, Health Care Boston Children's Hospital, Dr Amy Starmer, Dr Christopher Landrigan, Handoff Communication, Medical Errors.


Streamlining patient handoffs safely and efficiently has long flummoxed medical professionals.
Those mistakes could have grave consequences — according to the Joint Commission, as many as 80 percent of all hospital sentinel events stem at least in some part from handoff miscommunications. It’s not easy changing the routines of providers, nor is establishing universal procedures that are useful for individuals with disparate backgrounds and responsibilities.
A patient handoff is ideally marked by a face-to-face discussion between providers, outlining both a patient’s progress and their further instructions for care. But a multitude of factors disturb handoffs, according to Mary Ann Friesen, nursing research coordinator for Falls Church, Va.-based Inova Hospital Systems, who has studied the handoff process extensively.
But developers say they are finding mobile technology solutions to the quandaries handoffs present. Subramanian’s firm studied evidence-based best practices of handoff models in order to formulate a mobile-based platform easing communication between practitioners and other staff at Marin General. Handoff app developers have had to find a balance between efficient standardization and useful customization. In the mid-2000s, Berkowitz helped create ExpectED, a web-based app that allowed physicians to notify an emergency department of an incoming patient. Some apps are being developed for nursing professionals, among them the Digital Nurse Assistant, developed by Xerox.
Each patient’s record contains the most relevant clinical information to support the nurses’ workflow. Plummer said that DNA would be especially helpful in avoiding “collisions” — those moments when nurses and ancillary staff need to provide care at the same time.
App developers must also consider their platform’s relation to electronic medical records (EMRs). Without the information gathered during the 2009 and 2011 Patient Safety Culture Surveys, the tool might not have been implemented, so be sure to take this yeara€™s survey!
The tool is intended to significantly reduce the likelihood that information will be missed during shift change. For instance, evidence suggests that overtime decreases when shift-change tools are in place.
For example, conducting the handoff in the patienta€™s room rather than at the nursing station or in the hallways provides the oncoming nurse the help of a second person in case a patient needs to be repositioned. Recent reviews of patient safety and satisfaction at Inova identified the shift-to-shift handoff as a process in need of improvement. The handoff procedure is a crucial part of patient care, and standards to strengthen it were implemented in 2011 by the Accreditation Council for Graduate Medical Education (ACGME). 6 in the New England Journal of Medicine, study results showed that I-PASS—an original system of bundled communication and training tools for handoff of patient care between providers—can increase patient safety without significantly burdening existing clinical workflows.
An estimated 80 percent of the most serious medical errors can be linked to communication between clinicians, particularly during patient handoffs. Boston Children’s served as the lead site for the study, while Brigham and Women’s served as the data coordinating center. During the six-month intervention phase, residents were trained on I-PASS handoff processes and required to use the system going forward.
The researchers noted significant improvements in residents’ oral and written communications at every center and a significant increase in residents’ satisfaction with the quality of their patient handoffs after I-PASS implementation, according to a post-study survey.
And while not documented in the study, they believe that the safety improvements supported by I-PASS adoption could lead to substantial reductions in medical error-related health care costs. Department of Health and Human Services (grant number R18AE000029), as well as the Agency for Healthcare Research and Quality (grant number K12HS019456), the Medical Research Foundation of Oregon, Physician Services Incorporated Foundation and Pfizer (unrestricted medical education grant), as well as input from the Initiative for Innovation in Pediatric Education and the Pediatric Research in Inpatient Settings Network. Starmer, MD, MPH, has indicated to Physician’s Weekly that she has worked as a consultant for the I-PASS Institute, overseeing the implementation of I-PASS at MD Anderson, Massachusetts General Hospital, and New York-Presbyterian Hospital. Starmer and colleagues developed an enhanced bundle of handoff interventions centered around a new mnemonic to standardize oral and written handoffs.
Starmer and colleagues examined the effect of the I-PASS program in pediatric inpatient units at nine academic hospitals. Furthermore, significant increases were seen in the inclusion of all pre-specified key elements in written documents and oral communication during handoff. Development, implementation, and dissemination of the I-PASS handoff curriculum: a multisite educational intervention to improve patient handoffs.
Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program requirements. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.
The workshop was based on best practices for handoffs using elements of the TeamSTEPPS communication programme, developed by the military and the US Agency for Healthcare Research and Quality.


Face-to-face handoffs were also restructured to involve all team members and minimize interruptions and distractions. In order to post comments, please make sure JavaScript and Cookies are enabled, and reload the page.
Numerous factors can impede clear communication between practitioners during transitions of care, among them being incomplete charts, forgotten or indecipherable instructions, and personal conflicts between providers. But mobile software developers are stepping up to face the myriad challenges handoffs present. Among them are Siva Subramanian, founder and chief operating officer of CareInSync in Santa Clara, Calif. They have numerous factors to consider, among them team members working in different departments, specialties and professions.
But in the app’s early stages of testing, he discovered it wasn’t transmitting much information useful to triage nurses, who evaluated patients with an established scoring system.
The app platform, developed for tablet devices at using research conducted by PARC, a Xerox Company, consolidates patient information that previously may have been in discrete silos, according to Deri Plummer, a Xerox product leader based in Franklin, Tenn.
Nurses can also choose to be notified about specific events, such as when a medication arrives that is due to be administered, or if a patient is cleared to go home. His company’s app structures tasks and communications throughout the day, not just at handoff time.
In addition to measuring traditional metrics for patient safety, this yeara€™s survey will measure how well UNC Hospitalsa€™ units and outpatient clinics recognize the effects of stress as well as their levels of resilience. Inova responded by convening a quality-improvement team to develop a new strategy for conducting the shift-to-shift handoff, one that standardizes procedures and incorporates a bedside component. But what step would the resident take next, when the patient developed a cardiac arrhythmia due to intraoperative blood loss or fluid shifts at 2 a.m.?
For example, a handoff-related medical error could occur if information about a critical diagnostic test is not communicated correctly between providers at shift change; the result could be a potentially harmful delay in patient care.
Starmer, MD, MPH and colleagues found that bundling handoff interventions appeared to reduce medical error rates and improve communications between residents changing shifts at a single institution.
The mnemonic was I-PASS, which stands for illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver. It measured rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow in more than 10,700 patient admissions.
This replaced the previous method of information exchange that required clinicians to manually enter and re-enter information in a word processing document, increasing the potential for human error. In addition, following the intervention, providers spent more time communicating face-to-face in quiet areas conducive to conversation, and spent more time at the bedside with patients. Utilizing smartphone and tablet platforms, they’re attempting to both stratify and simplify communication between caregivers. Lyle Berkowitz, associate chief medical officer of innovation at Northwestern Memorial Hospital in Chicago, likens a handoff to engagement on Twitter. Wohlauer, surgical resident at the University of Colorado Medical Center in Aurora, Colo., the handoff should function the same as a well-written user’s manual. The firm’s handoff app, Carebook, went live at Marin General Hospital in Greenbrae, Calif., and eight of its satellite facilities in December. Wohlauer said patients might not want some handoff information — such as notes about disruptive family members — included with their permanent medical records.
Would it be something the junior resident had decided on the fly, or had a senior attending physician already envisioned this possibility and discussed how to respond, hours before? With more groups of people overseeing patients in an era of restricted medical resident work hours, the potential for missed details has increased.
Additional elements of the I-PASS handoff bundle included faculty development, observations of live handoffs, a visual reinforcement campaign, and training sessions that included simulation and role play exercises. The material on this site is for informational purposes only, and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.
The app allows for real-time communication between team members, customizable checklists and onscreen dashboards, among other components. The proposed project aims to 1) measure patient satisfaction and perceptions regarding the ISHAPED bedside handoff process, 2) use the patient feedback to optimize and standardize the bedside handoff process, and 3) develop a training video and companion toolkit to educate nurses on how to conduct a safe, effective and patient-centered bedside hand-off across multiple settings.



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