Reducing Medical Errors in Patient Handoffs

Creagh, Hughes, and Nego

Recent News
April 27, 2017

Creagh, Hughes, and Nego

Pediatric resident John Creagh and chief resident Helen Hughes follow the I-PASS patient handoff mnemonic as Thuy Ngo, associate director of the pediatric residency program, observes.

It’s no secret in the medical community that miscommunication during handoffs of patient care from one resident to another is a leading cause of serious medical errors. Indeed, the omission of critical information and the transfer of erroneous information during handoffs contribute to two of every three “sentinel events,” as reported in the April 2016 issue of the American Journal of Medical Quality.

To help reduce medical errors, the pediatric residency program at Johns Hopkins applied in 2016 to be part of a national quality improvement initiative called I-PASS. A mnemonic for handoff communication, I-PASS stands for illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by receiver.

“The mnemonic provides a standardized structure to improve how pediatric residents communicate with each other — both verbally and on paper — when transferring the care of a patient,” says chief resident Helen Hughes, who, with Thuy Ngo, associate director of the residency program, led I-PASS training at the Johns Hopkins Children’s Center. “We do the teaching, and faculty members observe the residents transferring care and assess whether they are using the mnemonic and the quality of the handoff communication.”

The results? Although the medical error rates before and after the intervention have not yet been reported, the quality of the written and oral handoff communications improved significantly with adherence to all elements in the I-PASS mnemonic since the start date.

“Recent data show our residents are using an evidence-based method for transferring information about patients during handoffs, which is helping to improve patient safety,” says Hughes. “And the majority of our residents—over 90 percent—recognized that I-PASS is effective in enhancing patient safety.”

Still, there’s room for improvement, says Ngo, who notes that a key goal of the mnemonic is for the handoff residents to achieve a “shared mental model” of the patient’s condition, care and treatment plan. That, she adds, requires more “thinking ahead” in the written document about the patient’s needs after the handoff.

“We’re doing better with the verbal handoffs, but I feel that sometimes our residents use the written handoffs as sort of a tally of what’s been going on with the patient’s hospitalization, as opposed to what the next person coming on shift needs to know and think about,” says Ngo. “We need to see more ‘if … then’ statements—‘If this happens to the patient, then do this’—for the night resident who hasn’t been there all day.”

Regarding the initiative’s potential for reducing medical errors, a  2014 New England Journal of Medicine  study showed that the I-PASS handoff bundle was associated with a 23 percent relative reduction in the overall medical error rate across nine training sites. The study also found a 30 percent relative reduction in the rate of preventable adverse events and significant decreases in rates of specific types of medical errors, including diagnostic errors.

The I-PASS Mentored Implementation Program is a collaboration with the Society of Hospital Medicine and funded by the Agency for Healthcare Research and Quality. Johns Hopkins pediatric residents’ participation in the I-PASS initiative was funded, in part, by the Johns Hopkins Children’s Center’s annual Radiothon.


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