Improved Communication at Handoff Can Cut Medical Errors, New England Journal of Medicine Reports

Having a system in place to reduce miscommunications between health-care providers during shift changes was shown to reduce preventable medical errors by 23 percent and the rate of preventable adverse events decreased by 30 percent, according to research recently published in the New England Journal of Medicine.

Dr. Amy J. Starmer of Boston Children’s Hospital led the study, which looked at the effectiveness of a resident handoff-improvement program at nine hospitals in terms of medical error rates, preventable adverse events, miscommunications, and resident workflow.

The program, called I-PASS (a mnemonic that stands for illness severity, patient summary, action list, situational awareness and contingency planning and synthesis by receiver), was designed to improve patient safety and reduce medical errors. It involves the following methods:

• Standardizing oral and written handoffs.
• A verbal handoff process.
• Computerized handoff tools.
• Attending physician supervision of the handoff process.
• A campaign to institutionalize I-PASS.

‘Two of the Most Significant Causes of Medical Errors’

“Miscommunications and handoff errors are two of the most significant causes of medical errors in hospitals in the U.S.,” Dr. Christopher Landrigan of Boston Children’s Division of General Pediatrics explained in a hospital press release published by Science Daily. Dr. Landrigan was a principal investigator and a lead author of the study.

At each of the nine participating hospitals, patient handoffs were measured by a six-month pre-intervention period, followed by a six-month intervention phase during which residents were trained on I-PASS procedures and required to use them moving forward. A final six-month period monitored and assessed the intervention.

Researchers found the implementation of I-PASS decreased the rate of preventable adverse events from 4.7 per 100 admissions to 3.3 per 100 admissions, according to the press release.

“This is the first multicenter handoff improvement program that has been found to reduce injuries due to medical errors,” Dr. Landrigan said.

Widespread Applicability?

Not only did the program reduce preventable medical errors, it also had no negative impact on doctors’ workflow, Dr. Starmer told CBS News. Better yet, I-PASS may be widely applicable.

“We are really excited about the study,” Dr. Starmer said. “Not only do we see a dramatic reduction in medical errors, but we found that this method is adaptable to other hospitals and to other health care workers, such as nurses and surgeons.”

Research published in Applied Radiology indicates that, among incidents resulting in medical malpractice claims, around 80 percent of the most serious medical errors are attributable to communication between clinicians. An example of a handoff-related medical error is when the results of a diagnostic test aren’t properly communicated between providers at shift change – an oversight that could lead to a delay in patient care and, as a result, patient harm.

“Because we know that miscommunications so commonly lead to serious medical errors, and because the frequency of handoffs in the hospital is increasing, there is no question that high-quality handoff improvement programs need to be a top priority for hospitals,” Starmer said in the press release.

The attorneys of Morrow Kidman Tinker Macey-Cushman, PLLC represent patients who have been harmed by preventable medical errors in Seattle and across Washington.