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Changes in medical errors after implementation of a handoff program
Amy J Starmer1, Nancy D Spector, Rajendu Srivastava
1From the Department of Medicine, Division of General Pediatrics, Boston Children's Hospital (A.J.S., T.C.S., C.P.L., A.D.A., E.L.N., L.L.T.), Harvard Medical School (A.J.S., A.K.D., S.R.L., J.M.R., T.C.S., C.P.L.), Center for Patient Safety Research, Division of General Medicine (A.K.D., C.A.K., J.M.R., S.R.L., M.F.W., C.S.Y., K.R.Z.) and Division of Sleep Medicine (C.P.L.), Brigham and Women's Hospital, and CRICO/Risk Management Foundation (C.A.K.) - all in Boston; the Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health and Science University, Portland (A.J.S., M.A.); the Department of Pediatrics, Section of General Pediatrics (N.D.S.) and Section of Critical Care (S.C.), St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia; the Departments of Pediatrics (R.S., J.B.S., A.T.S.) and Neurology (J.F.B.), Primary Children's Hospital, Intermountain Healthcare, University of Utah School of Medicine, and Institute for Health Care Delivery Research, Intermountain Healthcare (R.S.), Salt Lake City; the Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco (D.C.W., G.R.), and the Department of Pediatrics, Division of General Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto (R.L.B., L.A.D., J.L.E., S.J.P.) - both in California; the Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora (K.M.W.); the Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati (J.K.O., L.G.S.); the Department of Paediatrics (Z.B., M.C., S.M.), Centre for Quality Improvement and Patient Safety (M.C.), and Institute for Health Policy, Management and Evaluation (S.M.), Hospital for Sick Children and University of Toronto, Toronto; the Department of Pediatrics, Division of General Pediatrics, Kapi'olani Medical Center for W
Implementing a structured resident handoff program significantly reduced medical errors and preventable adverse events. This initiative improved communication without negatively impacting resident workflow or patient care time.
Area of Science:
- Medical error reduction
- Healthcare communication
- Patient safety
Background:
- Miscommunications are a primary cause of medical errors.
- Multicenter data on handoff improvement programs are limited.
Purpose of the Study:
- To assess the impact of a resident handoff improvement program on medical errors and patient safety.
- To evaluate changes in communication and resident workflow.
Main Methods:
- Prospective intervention study across nine hospitals.
- Standardized oral/written handoffs using a mnemonic, communication training, and faculty development.
- Active surveillance for medical errors and adverse events; document/audio review for handoffs; time-motion observations for workflow.
Main Results:
- Medical error rate decreased by 23% (24.5 to 18.8 per 100 admissions).
- Preventable adverse event rate decreased by 30% (4.7 to 3.3 per 100 admissions).
- Significant improvements in key elements of written and oral handoffs; no significant changes in handoff duration or resident workflow.
Conclusions:
- The handoff program effectively reduced medical errors and preventable adverse events.
- Communication quality improved without adverse effects on resident workflow.
- This multicenter study demonstrates the value of structured handoff programs in enhancing patient safety.
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