Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

December 2018

· HAI Rates Drop

· Cost Savings from Eliminating Unnecessary Telemetry

· Joint Commission Ambulatory NPSG’s for 2019

· Handoffs Don’t Predict Everything

HAI Rates Drop

In 2016 there was a substantial reduction in hospital-acquired infections compared to 2015. According to the CDC (CDC 2018) the following reductions took place in US hospitals between 2015 and 2016:

· CLABSI’s decreased 11%

· CAUTI’s decreased 7%

· MRSA bacteremia decreased 6%

· C. diff events decreased 8%

· Ventilator-associated events decreased 2%

· SSI’s for abdominal hysterectomy decreased 13%

· SSI’s for colon surgery decreased 7%

Another recently published study on a sample of hospitals in 10 states (Magill 2018) had shown patients’ risk of having a health care–associated infection was 16% lower in 2015 than in 2011.

And, according to AHRQ (AHRQ 2018a), data for 2014 through 2016 continue to show a downward trend in hospital-acquired conditions (which include much more than hospital-acquired infections) previously reported for 2010 to 2014. From 2010 through 2014, the rate of hospital-acquired conditions (HACs) decreased 17 percent. New data for 2014 to 2016 show an 8 percent decrease.

Various programs in hospitals have had positive roles in reducing infections, including LEAN Six Sigma (Improta 2017), leadership rounds (Knobloch 2017), a vascular access midlines program (Pathak 2018), hospital staffing (Mitchell 2018), and the U.S. Department of Health and Human Services (HHS) Partnership for Patients (PfP) initiative, which was started in 2011 (AHRQ 2016). Researchers at Regenstrief Institute and Indiana University School of Medicine (Azar 2018) borrowed a tool from software development, called “agile implementation”, to reduce CLABSI’s by 30% and also reduce C. diff infections and SSI’s. A change in culture that occurred during the implementation process was considered a key factor in its success.

IBM Watson Health (IBM Watson Health 2018) looked at HAC’s (hospital acquired conditions) in 2016 to assess both the human and financial costs of HAC’s. Keep in mind that hospital-associated infections are only are part of the overall spectrum of HAC’s. They found that there were over 48,000 HAC’s in 2016 and that these resulted in over 3000 potentially avoidable deaths. Moreover, this was associated with more than $2 billion in excess hospital costs. That calculates out to an average excess hospital cost of $41,917 per HAC patient. These HAC’s added, on average, 8.17 days per patient to average length of stay. They increased mortality risk per patient by 72.32%.

Another study (Anand 2018) looking at cost aspects of various inpatient harms found that surgical site infections were associated with about $30,000 additional costs per case. Hospital‐associated urinary tract infections added $6000 to $13,000 per case. Patients with preventable hospital-acquired conditions were also more likely to be readmitted within 90 days.

Some may be surprised by the cost of CAUTI’s in the Anand study. We’ve previously noted wide variation in the “attributable” costs of CAUTI’s (attributable costs are costs that would not have been incurred had the CAUTI not occurred). In our April 3, 2018 Patient Safety Tip of the Week “Cost of a CAUTI” we highlighted a systematic review which showed the attributable costs of CAUTI’s are very dependent upon the nature of the patient population and location of services (Hollenbeak 2018). From that review the authors note the attributable costs of a CAUTI were: $876 (inpatient cost to the hospital for additional diagnostic tests and medications); $1,764 (inpatient cost to Medicare for non-intensive care unit [ICU] patients); $7,670 (inpatient and outpatient costs to Medicare); $8,398 (inpatient cost to the hospital for pediatric patients); and $10,197 (inpatient cost to Medicare for ICU patients).

One of the studies mentioned above (Magill 2018) noted there is still a need for further efforts to reduce C. diff related events. While the reduction in C. diff related events in 2016 (CDC 2018) is encouraging, there has also been evidence that C. diff related events are becoming more prevalent outside the hospital (Dalton 2018, Khanna 2012).

In addition to the numerous resources on preventing HAI’s in our multiple columns below, there a couple resources we’ve not previously mentioned. AHRQ (AHRQ 2018b) provides a variety of toolkits and resources to help healthcare organizations reduce the various hospital-acquired conditions. And APIC (Association for Professionals in Infection Control and Epidemiology) provides “Quick Infection Prevention Observation Tools”.

Some of our prior columns on HAI’s (hospital-acquired infections):

December 28, 2010 “HAI’s: Looking In All The Wrong Places”

October 2013 “HAI’s: Costs, WHO Hand Hygiene, etc.”

February 2015 “17% Fewer HAC’s: Progress or Propaganda?”

April 2016 “HAI’s: Gaming the System?”

September 2016 “More on Preventing HAI’s”

November 2018 “Privacy Curtains Shared Rooms and HAI’s”

Some of our other columns on central venous catheters and PICC lines:

January 21, 2014 “The PICC Myth”

December 2014 “Surprise Central Lines”

July 2015 “Reducing Central Venous Catheter Use”

October 2015 “Michigan Appropriateness Guide for Intravenous Catheters”

March 27, 2018 “PICC Use Persists”

Our other columns on urinary catheter-associated UTI’s:

May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?”
January 8, 2008 Tip of the Week “Urinary Catheter-Associated Infections”
April 2008 What’s New in the Patient Safety World column “More on Nosocomial UTI’s”
June 24, 2008 Tip of the Week “Urinary Catheter-Related UTI’s: Bladder Bundles”
April 21, 2009 Tip of the Week “Still Futzing with Foleys?”
June 9, 2009 Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI”
March 2010 “IDSA CAUTI Guidelines”
February 2011 What’s New in the Patient Safety World column “Catheters Not Needed in C-Sections?”
January 2012 “CAUTI’s Still Get No Respect”
May 2012 “Foley Catheter Hazards”
November 2012 “CAUTI Conundrum”
December 18, 2012 “Unintended Consequences of the CAUTI Measure?”
January 2013 “Silver-Coated Urinary Catheters Don’t Reduce CAUTI’s”
June 2013 “Barriers to CAUTI Prevention”
November 2013 “Further Reducing Urinary Catheter Use”
June 2014 “Updated HAI Prevention Guidelines from SHEA/IDSA”
June 30, 2015 “What Are Appropriate Indications for Urinary Catheters?”
December 2015 “CAUTI Prevention Tools”
July 2016 “Holy Moly, My Patient has a FOLEY!”
December 2016 “The Joint Commission NPSG for CAUTI’s”
April 3, 2018 “Cost of a CAUTI”
September 25, 2018 “Foley Follies”

Some of our other columns on handwashing and hand hygiene:

January 5, 2010 “How’s Your Hand Hygiene?”

December 28, 2010 “HAI’s: Looking In All The Wrong Places”

May 24, 2011 “Hand Hygiene Resources”

October 2011 “Another Unintended Consequence of Hand Hygiene Device?”

March 2012 “Smile…You’re on Candid Camera”

August 2012 “Anesthesiology and Surgical Infections”

October 2013 “HAI’s: Costs, WHO Hand Hygiene, etc.”

November 18, 2014 “Handwashing Fades at End of Shift, ?Smartwatch to the Rescue”

January 20, 2015 “He Didn’t Wash His Hands After What!”

September 2015 “APIC’s New Guide to Hand Hygiene Programs”

November 2015 “Hand Hygiene: Paradoxical Solution?”

April 2016 “Nudge: An Example for Hand Hygiene”

August 2016 “Hand Hygiene: Who’s Watching? Does it Matter?”

September 2016 “More on Preventing bookmark’s”

July 18, 2017 “Another Hazard from Alcohol-Based Hand Gels”

Some of our prior columns on antibiotic stewardship:

October 14, 2014 “Antibiotic Stewardship”
November 2015 “Medications Most Likely to Harm the Elderly Are…”
July 2016 “NQF/CDC Guideline on Antibiotic Stewardship”
August 2016 “Some Reassurance on Antibiotic Stewardship”
November 2016 “C. Diff and Your Predecessor’s Room”
December 2016 “Update on Ambulatory Antibiotic Stewardship”
July 2017 “Antibiotics and Adverse Events”

References:

CDC (Centers for Disease Control and Prevention). Healthcare-Associated Infection (HAI) Data for Various Healthcare Settings. CDC 2018

https://gis.cdc.gov/grasp/PSA/HAIreport.html

Magill SS, O’Leary E, Janelle SJ, et al. Changes in Prevalence of Health Care–Associated Infections in U.S. Hospitals. N Engl J Med 2018; 379: 1732-1744

https://www.nejm.org/doi/full/10.1056/NEJMoa1801550

AHRQ (Agency for Healthcare Research and Quality). AHRQ National Scorecard on Hospital-Acquired Conditions. Updated Baseline Rates and Preliminary Results 2014–2016. AHRQ 2018; June 2018

https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf

Improta G, Cesarelli M, Montuori P, et al. Reducing the risk of healthcare‐associated infections through Lean Six Sigma: The case of the medicine areas at the Federico II University Hospital in Naples (Italy). Journal of Evaluation in Clinical Practice 2017; 24(2): 338-346 First published: 03 November 2017

https://onlinelibrary.wiley.com/doi/full/10.1111/jep.12844

Knobloch MJ, Chewning B, Musuuza J, et al. Leadership rounds to reduce health care–associated infections. American Journal of Infection Control 2018; 46(3): 303-310 Published online: November 2, 2017

https://www.ajicjournal.org/article/S0196-6553(17)31053-2/fulltext

Pathak R, Gangina S, Jairam F, Hinton K. A vascular access and midlines program can decrease hospital-acquired central line-associated bloodstream infections and cost to a community-based hospital. Therapeutics and Clinical Risk Management 2018: 14: 1453-1456

https://www.dovepress.com/a-vascular-access-and-midlines-program-can-decrease-hospital-acquired--peer-reviewed-article-TCRM

Mitchell BG, Gardner A, Stone PW, at al. Hospital Staffing and Health Care–Associated Infections: A Systematic Review of the Literature. Joint Commission Journal on Quality and Patient Safety 2018; 44(10): 613-622

https://www.jointcommissionjournal.com/article/S1553-7250(17)30538-X/fulltext

AHRQ (Agency for Healthcare Research and Quality). National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data from National Efforts to Make Health Care Safer. AHRQ 2016

http://www.ahrq.gov/professionals/quality-patient-safety/pfp/2015-interim.html?utm_source=AHRQ&utm_medium=PR&utm_term=&utm_content=6&utm_campaign=AHRQ_NSOHAC_2016

Azar J, Kelley K, Dunscomb J, et al. Using the Agile Implementation Model to Reduce Central Line-associated Blood Stream Infections. Am J Infect Control 2018; Published online September 7, 2018

https://www.ajicjournal.org/article/S0196-6553(18)30751-X/fulltext

IBM Watson Health. Hospital-Acquired Conditions lead to avoidable cost and excess deaths. IBM Watson Health 2018

https://www-01.ibm.com/common/ssi/cgi-bin/ssialias?htmlfid=51020151USEN&

Anand P, Kranker K, Chen AY. Estimating the hospital costs of inpatient harms. Health Serv Res 2018; Early View published online Oct 11, 2018

https://onlinelibrary.wiley.com/doi/abs/10.1111/1475-6773.13066

Hollenbeak CS, Schilling AL. The attributable cost of catheter-associated urinary tract infections in the United States: A systematic review. Am J Infect Control 2018; Published online: February 22, 2018

http://www.ajicjournal.org/article/S0196-6553(18)30036-1/fulltext

Dalton C. Dangerous Infection Tied To Hospitals Now Becoming Common Outside Them. NPR Vermont Public Radio 2018; November 25, 2018

https://www.npr.org/sections/health-shots/2018/11/25/657861409/dangerous-infection-tied-to-hospitals-now-becoming-common-outside-them

Khanna S, Pardi DS, Aronson SL, et al. The epidemiology of community-acquired Clostridium difficile infection: a population-based study. Am J Gastroenterol 2012; 107(1): 89-95. Epub 2011 Nov 22

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3273904/

AHRQ (Agency for Healthcare Research and Quality). AHRQ's Healthcare-Associated Infections Program. Accessed October 15, 2018

https://www.ahrq.gov/professionals/quality-patient-safety/hais/index.html?utm_source=AHRQ&utm_medium=psls&utm_term=&utm_content=3&utm_campaign=AHRQ_ipw_2018

APIC (Association for Professionals in Infection Control and Epidemiology). Quick Infection Prevention Observation Tools. APIC 2018

http://ipcobservationtools.site.apic.org/observation-tools-library/

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Cost Savings from Eliminating Unnecessary Telemetry

In our numerous columns on alarm fatigue and alarm management, we’ve emphasized that the first place to look to reduce unnecessary alarms is usually telemetry (see our columns for July 2, 2013 “Issues in Alarm Management”, October 2014 “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”, and August 16, 2016 “How Is Your Alarm Management Initiative Going?”).

In addition to the beneficial patient safety aspect of reducing unnecessary alarms that might contribute to alarm fatigue, there is also a potential for cost savings. A new study (Chong-Yik 2018) demonstrates the considerable cost savings when you limit use of telemetry to those patients meeting the AHA/ACA guidelines for telemetry. The researchers reviewed 250 consecutive patients admitted to telemetry capable beds on the general medical-surgical, noncritical care units at a tertiary care hospital. Only 24% of telemetry days were deemed appropriate based on the American Heart Association Practice Standards for Electrocardiographic Monitoring in Hospital Settings (Drew 2004, Sandau 2017). The cost of telemetry was calculated as $34.28 more per day than a nontelemetry hospital day. They calculated that elimination of inappropriate telemetry days would result in a minimum estimated savings of $37,007 in these 250 patients, and an annual savings of $528,241 overall. Importantly, no cardiac code call occurred on a “nontelemetry” day (codes on patients not meeting the criteria were for respiratory events rather than cardiac events). Of 16 significant arrhythmias detected by telemetry, all were on appropriate telemetry days. Of 19 significant clinical decisions were prompted by telemetry, only one was on a “nontelemetry” day.

Many hospitals have never developed local guidelines to help identify which patients should be monitored by telemetry (and which should not). Moreover, criteria for continued monitoring are extremely important because all too often a physician orders telemetry and it gets continued indefinitely. Getting your physician staff involved early in developing your telemetry criteria is the key.

In our October 2014 What's New in the Patient Safety World column “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring” we cited a study at Christiana Care Health System that successfully implemented a system that significantly reduced unnecessary non-ICU telemetry and achieved substantial financial savings while not adversely impacting patient safety (Dressler 2014). A multidisciplinary team designed the program and ensured appropriate training of impacted departments. The key component was hardwiring the AHA guidelines into their electronic ordering system. Providers were now required to choose an indication from a list, each of which included a duration based upon the AHA guidelines. In addition, they removed telemetry orders from order sets for conditions where monitoring was not supported by the AHA guidelines. Also, guidelines were established for automatic discontinuation of telemetry monitoring.

Focusing on unnecessary telemetry monitoring can lead to significant financial savings without sacrificing patient safety and likely reducing alarm fatigue.

Prior Patient Safety Tips of the Week pertaining to alarm-related issues:

March 5, 2007 “Disabled Alarms”
March 26, 2007 “Alarms Should Point to the Problem”
April 2, 2007 “More Alarm Issues”
June 19, 2007 “Unintended Consequences of Technological Solutons”
April 1, 2008 “Pennsylvania PSA’s FMEA on Telemetry Alarm Interventions”
February 23, 2010 “Alarm Issues in the News Again”
March 2, 2010 “Alarm Sensitivity: Early Detection vs. Alarm Fatigue”
March 16, 2010 “A Patient Safety Scavenger Hunt”
November 2010 “Alarms in the Operating Room”
February 22, 2011 “Rethinking Alarms”
February 2013 “Joint Commission Proposes New 2014 National Patient Safety Goal”
May 2013 “Joint Commission Sentinel Event Alert: Alarm Safety”
July 2, 2013 “Issues in Alarm Management”
August 2013 “Joint Commission Formalizes 2014 NPSG on Alarm Management”
February 4, 2014 “But What If the Battery Runs Low?”
October 2014 “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”
December 15, 2015 “Vital Sign Monitoring at Night”
February 9, 2016 “It was just a matter of time…”
August 16, 2016 “How Is Your Alarm Management Initiative Going?”
February 21, 2017 “Alarm Fatigue in the ED”
April 18, 2017 “Alarm Response and Nurse Shift Duration”
April 25, 2017 “Dialysis and Alarm Fatigue”
October 17, 2017 “Progress on Alarm Management”
November 21, 2017 “OSA, Oxygen, and Alarm Fatigue”
May 1 2018 “Refrigerator Alarms”

References:

Chong-Yik R, Bennett AL, Milani RV, Morin DP. Cost-Saving Opportunities with Appropriate Utilization of Cardiac Telemetry. Am J Cardiol 2018; 122, Issue 9, Pages 1570–1573

https://www.ajconline.org/article/S0002-9149(18)31488-7/fulltext

Drew BJ, Califf RM, Funk M, Kaufman ES, Krucoff MW, Laks MM, Macfarlane PW, Sommargren C, Swiryn S, Van Hare GF, American Heart Association, Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young. Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientific statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young [published correction appears in Circulation. 2005;111:378]. Circulation 2004; 110: 2721-2746

https://www.ahajournals.org/doi/pdf/10.1161/01.CIR.0000145144.56673.59

Sandau KE, Funk M, Auerbach A, et al. AHA Scientific Statement. Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association. Circulation 2017; 136: e273-e344 Originally published October 3, 2017

http://circ.ahajournals.org/content/136/19/e273

Dressler R, Dryer MM, Coletti C, et al. Altering Overuse of Cardiac Telemetry in Non–Intensive Care Unit Settings by Hardwiring the Use of American Heart Association Guidelines. (Research Letter). JAMA Intern Med 2014; published online first September 22, 2014

http://archinte.jamanetwork.com/article.aspx?articleid=1906998

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Joint Commission Ambulatory NPSG’s for 2019

The Joint Commission recently released its Ambulatory NPSG’s (National Patient Safety Goals) for 2019 (TJC 2018a). These become effective January 1, 2019. They are listed below:

Identify Patients Correctly

· Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. (NPSG.01.01.01)

· Make sure that the correct patient gets the correct blood when they get a blood transfusion. (NPSG.01.03.01)

Use medicines safely

· Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up. (NPSG.03.04.01)

· Take extra care with patients who take medicines to thin their blood. (NPSG.03.05.01)

· Record and pass along correct information about a patient’s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. (NPSG.03.06.01)

Prevent infection

· Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning. (NPSG.07.01.01)

· Use proven guidelines to prevent infection after surgery. (NPSG.07.05.01)

Prevent mistakes in surgery

· Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s body. (UP.01.01.01)

· Mark the correct place on the patient’s body where the surgery is to be done. (UP.01.02.01)

· Pause before the surgery to make sure that a mistake is not being made. (UP.01.03.01)

Details with the elements of performance are included in the full chapter (TJC 2018b).

References:

The Joint Commission . Ambulatory Health Care National Patient Safety Goals. October 16, 2018

https://www.jointcommission.org/assets/1/6/2019_AHC_NPSGs_final.pdf

The Joint Commission . Ambulatory Health Care National Patient Safety Goals (chapter with elements of performance detailed). October 16, 2018

https://www.jointcommission.org/assets/1/6/NPSG_Chapter_AHC_Jan2019.pdf

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Handoffs Don’t Predict Everything

Arguably, the most important feature of the “signout” or handoff is the ability to anticipate events that might potentially occur on the next shift. But how good are we at anticipating actual events? A new study in an ICU setting provides some insight.

Dutra and colleagues in Brazil (Dutra 2018) analyzed 44 day-to-night handovers between intensivists in an ICU. They surveyed clinicians immediately after a handover and identified clinical events through chart abstractions and interviews with clinicians the next morning.

Nighttime clinicians correctly identified only 53% of diagnoses and 40% of goals shortly after the handoff. The positive predictive value of both daytime and nighttime clinicians for anticipating clinical events at night was low (13% vs 17%). Daytime clinicians were more sensitive (65% vs 46%) but less specific (82% vs 91%) than nighttime clinicians in anticipating clinical events at night. Handovers among staff intensivists showed more gaps in the identification of diagnostic uncertainty and for neurologic diagnoses.

The authors conclude that the expectation that anticipatory guidance can inform handovers needs to be balanced against information overload. Furthermore, they suggest that handovers could benefit from communication strategies such as cognitive checklists, prioritizing discussion of neurologic patients, and brief combined clinical examination at handover.

A previous study of pediatric resident handoffs (Borowitz 2008) showed similar problems in anticipating events. 31% of surveyed resident physicians indicated something happened while they were on call for which they were not adequately prepared. And in 82% of those instances, they indicated there was information they did not receive during sign-out that would have been helpful to them in caring for a patient overnight, And, of those, they indicated the situation should have been anticipated and discussed during sign-out in 82.5% of cases. Perhaps surprisingly, residents were no more likely to report events they were unprepared for when they were “cross-covering” at night than when they were members of the general pediatric ward team or if they had cared for the child previously.

Note that the Borowitz study was in the era before I-PASS became popular and successful as a format for handoffs. The I-PASS format stands for:

I: Illness Severity

P: Patient Summary

A: Action List

S: Situation Awareness and Contingency Planning

S: Synthesis by Receiver

The “S” for “situation awareness and contingency planning” obviously emphasizes the importance of anticipating things that might go wrong or events that might appear and stresses planning for contingencies.

Details on the format of I-PASS and reasons for its development can be found in our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” and our What’s New in the Patient Safety World columns for June 2012 “I-PASS Results and Resources Now Available” and December 2014 “I-PASS Passes the Test” and the I-PASS website. I-PASS is really much more than a handoff format. It really is part of a culture of patient safety.

Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:

May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”

May 22, 2007 “More on TeamSTEPPS™”

August 28, 2007 “Lessons Learned from Transportation Accidents”

December 11, 2007 “Communication…Communication…Communication”

February 26, 2008 “Nightmares….The Hospital at Night”

September 30, 2008 “Hot Topic: Handoffs”

November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”

December 2008 “Another Good Paper on Handoffs”.

June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”

April 25, 2009 “Interruptions, Distractions, Inattention…Oops!”

April 13, 2010 “Update on Handoffs”

July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”

July 19, 2011 “Communication Across Professions”

November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”

December 2011 “AORN Perioperative Handoff Toolkit”

February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”

March 2012 “More on Perioperative Handoffs”

June 2012 “I-PASS Results and Resources Now Available”

August 2012 “New Joint Commission Tools for Improving Handoffs”

August 2012 “Review of Postoperative Handoffs”

January 29, 2013 “A Flurry of Activity on Handoffs”

December 10, 2013 “Better Handoffs, Better Results”

February 11, 2014 “Another Perioperative Handoff Tool: SWITCH”

March 2014 “The “Reverse” Perioperative Handoff: ICU to OR”

September 9, 2014 “The Handback”

December 2014 “I-PASS Passes the Test”

January 6, 2015 “Yet Another Handoff: The Intraoperative Handoff”

March 2017 “Adding Structure to Multidisciplinary Rounds”

August 22, 2017 “OR to ICU Handoff Success”

October 2017 “Joint Commission Sentinel Event Alert on Handoffs”

October 30, 2018 “Interhospital Transfers”

References:

Dutra M, Monteiro MV, Ribeiro KB, et al. A Study of Information Loss and Clinical Accuracy to Anticipate Events. Crit Care Med 2018; 46(11): 1717-1721

https://journals.lww.com/ccmjournal/Abstract/2018/11000/Handovers_Among_Staff_Intensivists___A_Study_of.1.aspx

Borowitz SM, Waggoner-Fountain LA, Bass EJ, et al: Adequacy of information transferred at resident sign-out (in-hospital handover of care): A prospective survey. Qual Saf Health Care 2008; 17: 6-10

https://qualitysafety.bmj.com/content/17/1/6.long

I-PASS Study website.

http://www.ipasshandoffstudy.com/home

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