What’s New in the Patient Safety World
December 2014
I-PASS Passes the Test
Amongst our numerous columns on handoffs/handovers (see the full
list of prior columns at the end of today’s column) we’ve especially been fond
of the I-PASS handoff program. We first described it in our February 14, 2012
Patient Safety Tip of the Week “Handoffs
– More Than Battle of the Mnemonics”, a column that highlighted the need to
tailor handoff formats to the specific tasks at hand. I-PASS came about because
existing formats were not optimal for resident-to-resident handoffs. Then in
our June 2012 What’s New in the Patient Safety World
column “I-PASS
Results and Resources Now Available” we noted the release of the very
promising preliminary results of the I-PASS project.
Now the final
results of the I-PASS project have been published (Starmer
2014). After implementation
of I-PASS the rate of medical errors decreased by 23% and the rate of
preventable medical errors decreased by 30%. Significantly, there was no
increase in the amount of time spent on handoffs and there was no significant
change in resident workflow or the amount of resident contact with patients and
families.
Specific medical
error types reduced in the I-PASS collaborative included diagnostic errors,
errors related to medical history or physical examination, multifactorial errors,
and errors related to therapies other than medications or procedures. (Errors
related to medications, procedures, falls, and nosocomial infections did not
change.)
The reduction in
medical errors was significant at six of the nine sites participating. Study
authors had no explanation for the lack of improvement at three sites, since
they also demonstrated improved inclusion of key elements in the handoff
process.
Make no mistake,
I-PASS is much more than a mnemonic and format for handoffs. It also involves
extensive team training (based on TeamSTEPPS™) and
resident training modules, simulation and role playing, faculty development
resources and tools, direct observation of handoffs with feedback, and
generation of a printed handoff document that can be integrated with the
electronic medical record.
In our September 9,
2014 Patient Safety Tip of the Week “The
Handback” we noted that a recent collaboration
among 23 pediatric hospitals (Bigham
2014) demonstrated a significant decrease in handoff-related are
failures for multiple different handoff types. I-PASS was a format utilized in
that collaboration. The improvement project was guided by evidence-based
recommendations regarding handoff intent and content, standardized handoff
tools/methods, and clear transition of responsibility. Hospitals tailored
handoff elements to locally important handoff types. Examples of the handoff
types included shift-to-shift handoffs, emergency department to inpatient
handoffs, and perioperative to inpatient handoffs. Handoff-related care
failures decreased from 25.8% at baseline to 7.9% in the final intervention
period.
Compliance to critical components of the handoff process
improved, as did provider satisfaction. Key elements required, regardless of
the handoff type, were that active participation by both the sending and
receiving teams were required, discrete times
and mechanisms set aside for the
receiving team to ask questions, a proscribed script of important handoff elements
was available, and a “read back” summary of basic issues and next steps was
accessible. One very interesting finding was that even where baseline
compliance with individual elements was pretty good at baseline, relatively
small incremental improvements in those individual elements collectively led to
very good reductions in overall handoff failures.
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 June 2012 What’s New in the
Patient Safety World column “I-PASS
Results and Resources Now Available” as well as in the current article (Starmer
2014) and the I-PASS
website.
Though restrictions
on hours that residents may work have increased the number and complexity of
handoffs/handovers, most of the same issues apply to other physician coverage
arrangements. Yes, one resident just finishing a 24-hour shift may have to
leave immediately after morning rounds. But a physician in a community or rural
hospital who is covering for another physician also has competing requirements
for his/her time (eg. office hours, scheduled
surgery, etc.). And the same types of interruptions and distractions (phone
calls, pages, nurses or colleagues or families requesting information, etc.)
apply equally well to morning rounds or the physician cross-coverage handback.
Though neither the I-PASS collaborative nor the previously
mentioned pediatric collaborative (Bigham
2014) looked at the impact of the missed handoff issues on
patient harm or actual patient outcomes, we would certainly predict that
improvement in the handback process would likely
prevent many adverse events and outcomes. Both are very good studies and have
implications for all healthcare organizations, not just academic ones.
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”
References:
Starmer AJ, Spector ND, Srivastava
R, et al. Changes in Medical Errors after Implementation of a Handoff Program. N
Engl J Med 2014; 371: 1803-1812
http://www.nejm.org/doi/full/10.1056/NEJMsa1405556
Bigham MT, Logsdon TR, Manicone
PE, et al. Decreasing Handoff-Related Care Failures in Children’s Hospitals. Pediatrics
2014; 134:2 e572-e579; published ahead of print July 7, 2014,
I-PASS Study website.
http://www.ipasshandoffstudy.com/home
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