Development, implementation and evaluation of a patient handoff tool to improve safety in orthopaedic surgery

To develop, implement and test the effect of a handoff tool for orthopaedic trauma residents that reduces adverse events associated with the omission of critical information and the transfer of erroneous information.

Components of this project included a literature review, resident surveys and observations, checklist development and refinement, implementation and evaluation of impact on adverse events through a chart review of a prospective cohort compared with a historical control group.

Large teaching hospital.

Findings of a literature review were presented to orthopaedic residents, epidemiologists, orthopaedic surgeons and patient safety experts in face-to-face meetings, during which we developed and refined the contents of a resident handoff tool. The tool was tested in an orthopaedic trauma service and its impact on adverse events was evaluated through a chart review. The handoff tool was developed and refined during the face-to-face meetings and a pilot implementation. Adverse event data were collected on 127 patients (n = 67 baseline period; n = 60 test period).

A handoff tool for use by orthopaedic residents.

Adverse events in patients handed off by orthopaedic trauma residents.

After controlling for age, gender and comorbidities, testing resulted in fewer events per person (25-27% reduction; P < 0.10).

Preliminary evidence suggests that our resident handoff tool may contribute to a decrease in adverse events in orthopaedic patients.