I-pass, a mnemonic to standardize verbal handoffs

Improving clinical reasoning and communication during handover: An intervention study of the BRIEF-C tool

BACKGROUND

Existing handover communication tools often lack a clear theoretical foundation, have limited psychometric evidence, and overlook effective communication strategies for enhancing diagnostic reasoning. This oversight becomes critical as communication breakdowns during handovers have been implicated in poor patient care. To address these issues, we developed a structured communication tool: Background, Responsible diagnosis, Included differential diagnosis, Excluded differential diagnosis, Follow-up, and Communication (BRIEF-C). It is informed by cognitive bias theory, shows evidence of reliability and validity of its scores, and includes strategies for actively sending and receiving information in medical handovers.

DESIGN

A pre-test post-test intervention study.

SETTING

Inpatient internal medicine and orthopaedic surgery units at one tertiary care hospital.

INTERVENTION

The BRIEF-C tool was presented to internal medicine and orthopaedic surgery faculty and residents who participated in an in-person educational session, followed by a 2-week period where they practised using it with feedback.

MEASUREMENTS

Clinical handovers were audiorecorded over 1 week for the pre- and again for the post-periods, then transcribed for analysis. Two faculty raters from internal medicine and orthopaedic surgery scored the transcripts of handovers using the BRIEF-C framework. The two raters were blinded to the time periods.

RESULTS

A principal component analysis identified two subscales on the BRIEF-C: diagnostic clinical reasoning and communication, with high interitem consistency (Cronbach's alpha of 0.82 and 0.99, respectively). One sample t-test indicated significant improvement in diagnostic clinical reasoning (pre-test: M=0.97, SD=0.50; post-test: M=1.31, SD=0.64; t(64)=4.26, p<0.05, medium to large Cohen's d=0.63) and communication (pre-test: M=0.02, SD=0.16; post-test: M=0.48, SD=0.83); t(64)=4.52, p<0.05, large Cohen's d=0.83).

CONCLUSION

This study demonstrates evidence supporting the reliability and validity of scores on the BRIEF-C as good indicators of diagnostic clinical reasoning and communication shared during handovers.

Development and Evaluation of I-PASS-to-PICU: A Standard Electronic Template to Improve Referral Communication for Interfacility Transfers to the Pediatric ICU

BACKGROUND

Miscommunication during interfacility handoffs to a higher level of care can harm critically ill children. Adapting evidence-based handoff interventions to interfacility referral communication may prevent adverse events. The objective of this project was to develop and evaluate a standard electronic referral template (I-PASS-to-PICU) to improve communication for interfacility pediatric ICU (PICU) transfers.

METHODS

I-PASS-to-PICU was iteratively developed in a single PICU. A core PICU stakeholder group collaboratively designed an electronic health record (EHR)-supported clinical note template by adapting elements from I-PASS, an evidence-based handoff program, to support information exchange between referring clinicians and receiving PICU physicians. I-PASS-to-PICU is a receiver-driven tool used by PICU physicians to guide verbal communication and electronic documentation during PICU transfer calls. The template underwent three cycles of iterative evaluation and redesign informed by individual and group interviews of multidisciplinary PICU staff, usability testing using simulated and actual referral calls, and debriefing with PICU physicians.

RESULTS

Individual and group interviews with 21 PICU staff members revealed that relevant, accurate, and concise information was needed for adequate admission preparedness. Time constraints and secondhand information transmission were identified as barriers. Usability testing with six receiving PICU physicians using simulated and actual calls revealed good usability on the validated System Usability Scale (SUS), with a mean score of 77.5 (standard deviation 10.9). Fellows indicated that most fields were relevant and that the template was feasible to use.

CONCLUSION

I-PASS-to-PICU was technically feasible, usable, and relevant. The authors plan to further evaluate its effectiveness in improving information exchange during real-time PICU practice.

We've Got a New One-Exploring the Resident-Fellow New Admission Interaction and Opportunities for Enhancing Motivation

OBJECTIVE

To characterize the phases of a new admission interaction between collaborating pediatric residents and fellows; to explore trainee perspectives on motivating and demotivating qualities of that interaction; and to identify behaviors that lead to an optimal new admission interaction.

METHODS

The authors used modified grounded theory with experiential learning theory and self-determination theory as sensitizing concepts to conduct 6 focus groups and journey mapping at Stanford Children's Health from January to March 2021. The sessions were audio-recorded and transcribed verbatim. Two authors independently coded the transcripts and developed categories and themes using constant comparison, while a third author reviewed these findings. The qualitative data were triangulated with surveys and journey mapping data and conceptualized into a model of trainee motivation during the new admission interaction. They outlined an optimal new admission interaction using behaviors consistently described by participants as motivating.

RESULTS

Developing inter-trainee trust and educational buy-in is essential for both residents and fellows to feel intrinsically motivated and engaged during a new admission. Residents need to feel autonomous, competent, and related to the team in order to develop trust and buy-in. Fellows require assurance of patient safety to develop trust and a sense of self-efficacy in fostering resident growth to develop buy-in. Lack of trust or buy-in from either party leads to a cycle of trainee disengagement.

CONCLUSIONS

Trainee motivation and engagement with patient care can be impacted by discreet, modifiable behavior by their fellow or resident counterpart, which may help improve the quality of care delivered.

Harnessing the Power of Generative AI for Clinical Summaries: Perspectives From Emergency Physicians

STUDY OBJECTIVE

The workload of clinical documentation contributes to health care costs and professional burnout. The advent of generative artificial intelligence language models presents a promising solution. The perspective of clinicians may contribute to effective and responsible implementation of such tools. This study sought to evaluate 3 uses for generative artificial intelligence for clinical documentation in pediatric emergency medicine, measuring time savings, effort reduction, and physician attitudes and identifying potential risks and barriers.

METHODS

This mixed-methods study was performed with 10 pediatric emergency medicine attending physicians from a single pediatric emergency department. Participants were asked to write a supervisory note for 4 clinical scenarios, with varying levels of complexity, twice without any assistance and twice with the assistance of ChatGPT Version 4.0. Participants evaluated 2 additional ChatGPT-generated clinical summaries: a structured handoff and a visit summary for a family written at an 8th grade reading level. Finally, a semistructured interview was performed to assess physicians' perspective on the use of ChatGPT in pediatric emergency medicine. Main outcomes and measures included between subjects' comparisons of the effort and time taken to complete the supervisory note with and without ChatGPT assistance. Effort was measured using a self-reported Likert scale of 0 to 10. Physicians' scoring of and attitude toward the ChatGPT-generated summaries were measured using a 0 to 10 Likert scale and open-ended questions. Summaries were scored for completeness, accuracy, efficiency, readability, and overall satisfaction. A thematic analysis was performed to analyze the content of the open-ended questions and to identify key themes.

RESULTS

ChatGPT yielded a 40% reduction in time and a 33% decrease in effort for supervisory notes in intricate cases, with no discernible effect on simpler notes. ChatGPT-generated summaries for structured handoffs and family letters were highly rated, ranging from 7.0 to 9.0 out of 10, and most participants favored their inclusion in clinical practice. However, there were several critical reservations, out of which a set of general recommendations for applying ChatGPT to clinical summaries was formulated.

CONCLUSION

Pediatric emergency medicine attendings in our study perceived that ChatGPT can deliver high-quality summaries while saving time and effort in many scenarios, but not all.

Improvements in Interdisciplinary Communication Following the Implementation of a Standardized Handoff Curriculum: SAFETIPS (Statistics, Assessment, Focused Plan, Pertinent Exam findings, to Dos, If/Thens, Pointers/Pitfalls, and Severity of Illness)

Background Handoffs between medical providers serve a crucial patient safety function. While most published literature on the topic studies the handover process among physicians, robust literature is available on interdisciplinary medical communication. Little is known about the downstream effects of effective physician handover on subsequent physician and nursing interactions. Objective Our objective was to implement a handoff curriculum, SAFETIPS (Statistics, Assessment, Focused plan, pertinent Exam findings, To dos, If/thens, Pointers/pitfalls, and Severity of illness), for pediatric residents and to investigate its impact on nurses' perceptions of resident preparedness, efficiency, and competency. Methods Nurses were asked to score residents in five domains and describe the frequency of nurse-to-resident and resident-to-nurse interruptions. The survey was distributed before and after the SAFETIPS introduction. Results Statistical analysis revealed significant post-intervention mean score increases of one full point in four categories, namely organization and efficiency, communication, content, and clinical judgment. The percentage of nurses using the term "reasonable/relevant" to describe interactions with residents significantly increased from 45% to 76% (p = 0.004). The percentage of nurses reporting that residents gave "unsure response[s]," made decisions that differed from nurses' decisions, and made decisions without family/parental interests significantly decreased by 31 (p = 0.004), 22 (p = 0.034), and 30 (p = 0.002) percentage points, respectively. Conclusion The introduction of a structured handoff curriculum significantly improves communication among residents. This is then associated with improved interactions between residents and nurses.

A survey on the effects of patient safety training programs based on SBAR and FMEA techniques on the level of self-efficacy and observance of patient safety culture in Iran hospital, Shiraz in 2022-2023

BACKGROUND AND OBJECTIVE

Patient safety and medical personnel self-efficacy are among the main factors involved in providing quality health services. Moreover, safety culture in an organization is considered one of the most critical factors regarding patients' safety. Therefore, the present study aimed to determine the effects of patient safety programs based on Situation, Background, Assessment, Recommendation (SBAR) and Failure Model Effects Analysis (FMEA) techniques on self-efficacy and patient safety culture in Iran Hospital of Shiraz in 2022-2023.

MATERIALS AND METHODS

This two-stage quasi-experimental study was conducted in 2022-2033. Considering inclusion criteria, the present study included 80 nurses working in Iran Hospital. The participants were divided into groups of SBAR (40 participants) and FMEA (40 participants). All the data were collected using a Hospital Survey on Patient Safety Culture questionnaire and Sherer General Self-Efficacy Scale. Then, the collected data were analyzed using SPSS 13, Fisher's exact test, paired t-test, and independent t-test with a significant level of P < 0.05.

RESULTS

The mean score of total patient safety culture between the two groups was insignificant before the intervention (P = 0.58). However, it was more significant in the FMEA group than the SBAR group after the intervention (P < 0/05). In addition, the mean self-efficacy score between the two groups was insignificant before the intervention (P = 0.80). However, after the intervention, the mean score of the FMEA group was significantly higher than the SBAR group (P < 0.05).

CONCLUSION

According to the findings of this study, there is a meaningful relationship between patient safety training programs based on SBAR and FMEA techniques on patient safety and self-efficacy of nurses; however, FMEA training has more positive effects on self-efficacy and patient safety compared to other techniques. As a result, these techniques, along with other plans, are recommended to authorities in order to help improve patient safety.

Development and effectiveness of a metaverse reality-based family-centered handoff education program in nursing students

PURPOSE

Effective patient handoffs are vital in pediatric populations. This study aimed to develop and identify the impact of a metaverse-based handoff program using ZEPETO on nursing students' handoff competence, handoff self-efficacy, learning realism, and satisfaction.

DESIGN AND METHODS

This study used a non-randomized, pre-post nonequivalent group design to develop, implement, and verify a metaverse-based handoff simulation program in a nursing school in South Korea. We assigned 69 senior nursing students from a university to an experimental group or a control group. We developed a metaverse-based, handoff simulation program of family-centered care by building a pediatric intensive care unit (PICU) using ZEPETO. The program included an online lecture, a metaverse rounding discussion, and a metaverse-based handoff simulation of postoperative care for infants with congenital heart disease. We measured handoff competence, handoff self-efficacy, learning realism, and learning satisfaction pre- and post-program.

RESULT(S)

The experimental group showed significantly higher handoff self-efficacy than the control group (t = 3.17, p = 0.002). No significant differences were found in handoff competency, learning realism, or learning satisfaction between the groups.

CONCLUSION(S)

This study confirmed that a family-centered care-based handoff metaverse simulation program based on the experiential learning theory enhanced nursing students' handoff self-efficacy. The program equipped students to conduct safe and effective handoffs in real-world clinical settings by providing an immersive learning experience and emphasizing patient-centered communication.

PRACTICAL IMPLICATIONS

Based on these results, family-centered, handoff education programs are recommended to be developed that focus on learning realism and learning satisfaction to enhance nursing students' handoff competence.

Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress

BACKGROUND

Incident reports submitted during times of organizational stress may reveal unique insights.

PURPOSE

To understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge.

METHODS

We randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare.

RESULTS

Among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Reporters linked 7 events to COVID-19.

CONCLUSIONS

Skill-based errors were the most common contributing factors for medication safety events during a COVID-19 surge. Reporters rarely deemed events to be related to COVID-19, despite the tremendous strain of the surge on nurses. Future efforts to improve the utility of incident reports should emphasize the importance of describing work system factors.

Long-Term Sustainability and Adaptation of I-PASS Handovers

BACKGROUND

Inadequate communication during transitions of care is a major health care quality and safety vulnerability. In 2013 Massachusetts General Hospital (MGH) embarked on a comprehensive training program using a standardized handover system (I-PASS) that had been shown to reduce adverse events by 30% even when not completely executed on each patient. In this cross-sectional study, the authors sought to characterize handover practices six years later.

METHODS

Using a standardized interview tool, the researchers evaluated handovers between responding clinicians in 10 departments and then validated these findings through direct observations, allowing for flexibility and customization in the I-PASS elements. The study qualitatively compared I-PASS element use in verbal handovers to MGH early postintervention data, as well as verbal and written handovers with the I-PASS Study Group's postintervention results.

RESULTS

The authors observed 156 verbal and reviewed 182 written patient handovers. Ninety percent of departments adhered at least partially to the I-PASS system. Average handover duration ranged from 0.6 to 2.1 minutes per established patient. The service with best I-PASS adherence also consistently included the most information per unit of time. Acknowledging substantial differences in study technique, MGH adherence was, on average, comparable or better on all I-PASS elements in verbal handovers and on three of four elements of written handovers compared with the I-PASS Study Group's postintervention results.

CONCLUSION

Although uptake has varied across services, six years after hospitalwide implementation of I-PASS, the majority of services are performing structured and sequenced handovers, most of which include some elements of the I-PASS system. Those services with the best I-PASS adherence conducted the most efficient handovers.

OrthoPass: Long-term Outcomes following Implementation of an Orthopaedic Patient Handoff Template

Standardized handoff tools improve communication and patient care; however, their widespread use in surgical fields is lacking. OrthoPass, an orthopaedic adaptation of I-PASS, was developed in 2019 to address handoff concerns and demonstrated sustained improvements across multiple handoff domains over an 18-month period. We sought to characterize the longitudinal effect and sustainability of OrthoPass within a single large residency program 3.5 years after its implementation. This mixed methods study involved electronic handoff review for quality domains in addition to survey distribution and evaluation. We conducted comparative analyses of handoff adherence and survey questions as well as a thematic analysis of provider-free responses. We evaluated 146 electronic handoffs orthopaedic residents, fellows, and advanced practice providers 3.5 years after OrthoPass implementation. Compared with 18-month levels, adherence was sustained across five of nine handoff domains and was markedly improved in two domains. Furthermore, provider valuations of OrthoPass improved regarding promoting communication and patient safety (83% versus 70%) and avoiding patient errors and near misses (72% versus 60%). These improvements were further substantiated by positive trends in Agency for Healthcare Research and Quality Surveys on Patient Safety Culture hospital survey data. Thematic analysis of free responses shared by 37 providers (42%) generated favorable, unfavorable, and balanced themes further contextualized by subthemes. At 3.5 years after its introduction, OrthoPass continues to improve patient handoff quality and to support provider notions of patient safety. Although providers acknowledged the benefits of this electronic handoff tool, they also shared unique insights into several drawbacks. This feedback will inform ongoing efforts to improve OrthoPass.

Heuristics and biases in medical decision-making under uncertainty: The case of neuropronostication for consciousness disorders

Neuropronostication for consciousness disorders can be very complex and prone to high uncertainty. Despite notable advancements in the development of dedicated scales and physiological markers using innovative paradigms, these technical progressions are often overshadowed by factors intrinsic to the medical environment. Beyond the scarcity of objective data guiding medical decisions, factors like time pressure, fatigue, multitasking, and emotional load can drive clinicians to rely more on heuristic-based clinical reasoning. Such an approach, albeit beneficial under certain circumstances, may lead to systematic error judgments and impair medical decisions, especially in complex and uncertain environments. After a brief review of the main theoretical frameworks, this paper explores the influence of clinicians' cognitive biases on clinical reasoning and decision-making in the challenging context of neuroprognostication for consciousness disorders. The discussion further revolves around developing and implementing various strategies designed to mitigate these biases and their impact, aiming to enhance the quality of care and the patient safety.

Reduced Postdischarge Incidents After Implementation of a Hospital-to-Home Transition Intervention for Children With Medical Complexity

OBJECTIVES

Prior research suggests that errors occur frequently for patients with medical complexity during the hospital-to-home transition. Less is known about effective postdischarge communication strategies for this population. We aimed to assess rates of 30-day (1) postdischarge incidents and (2) readmissions and emergency department (ED) visits before and after implementing a hospital-to-home intervention.

METHODS

We conducted a prospective intervention study of children with medical complexity discharged at a children's hospital from April 2018 to March 2020. A multistakeholder team developed a bundled intervention incorporating the I-PASS handoff framework including a postdischarge telephone call, restructured discharge summary, and handoff communication to outpatient providers. The primary outcome measure was rate of postdischarge incidents collected via electronic medical record review and family surveys. Secondary outcomes were 30-day readmissions and ED visits.

RESULTS

There were 199 total incidents and the most common were medication related (60%), equipment issues (15%), and delays in scheduling/provision of services (11%). The I-PASS intervention was associated with a 36.4% decrease in the rate of incidents per discharge (1.51 versus 0.95, P = 0.003). There were fewer nonharmful errors and quality issues after intervention (1.27 versus 0.85 per discharge, P = 0.02). The 30-day ED visit rate was significantly lower after intervention (12.6% versus 3.4%, per 100 discharges, P = 0.05). Thirty-day readmissions were 15.8% versus 10.2% postintervention (P = 0.32).

CONCLUSIONS

A postdischarge communication intervention for patients with medical complexity was associated with fewer postdischarge incidents and reduced 30-day ED visits. Standardized postdischarge communication may play an important role in improving quality and safety in the transition from hospital-to-home for vulnerable populations.

Handoff Tool Improves Transitions from the Operating Room to the Neonatal Intensive Care Unit

Introduction

Standardized handoffs reduce medical errors and prevent adverse events or near misses. This article describes a quality improvement initiative implementing a unique standardized handoff tool and process to transition from the operating room to the neonatal intensive care unit (NICU) at a level-four regional center with many inpatients requiring surgical intervention. Before this project, there was no standardized handoff tool or process for postsurgical transitions. The primary aim was to achieve 80% compliance with completing a structured postoperative OR to NICU handoff tool within 12 months of implementation.

Methods

An interdisciplinary team developed and implemented a standardized NICU postoperative handoff tool and process that requires face-to-face communication, defines team members who should be present, and highlights communication with the family. In addition, the handoff tool compliance and process measures were monitored, evaluated, and audited.

Results

Although not consistent, we achieved eighty percent compliance with the outcome measures using the handoff tool. We did not sustain 80% of appropriate providers present at handoff. In addition, insufficient data assess overall parental satisfaction with the surgical experience. Although improved, the process measure of immediate postoperative family updates did not reach the targeted goal. However, the balancing measure of staff experience and satisfaction did improve.

Conclusion

Implementing a standardized handoff tool and process with an interdisciplinary and interdepartmental collaboration improves critical patient transitions from the operating room to the NICU.

Navigating quality and safety in your health system: understanding the alphabet soup

Entering any new healthcare system today requires thorough knowledge about its quality and safety structure and culture. Learning that language is generally the first step in gaining a better understanding of how systems function. This overview of common mnemonics in the quality and safety world will provide the reader with better comprehension of their quality systems within their institutions. Healthcare providers should understand how patient safety organizations were established and the importance of our safety event classification system, along with the ability to recognize gaps in care that highlight opportunities for improvement. In addition, this review provides explanations of error prevention tools used every day to help new colleagues communicate better and share situational awareness to keep patients safe. Lastly, utilization of standard quality improvement tools can facilitate quality improvement projects and assist all healthcare systems to become highly reliable organizations.

Evaluation of a Standard Handover Tool at a Pediatric Tertiary Care Unit in Oman

Background The handover system is a great communication tool physicians use to transfer and receive patients' care-related information. The introduction of structured handover tools has resulted in a dramatic reduction in hospital-acquired injuries. We hypothesize that the I-PASS handover tool will improve both written and verbal communication without compromising the handover duration. The current study aims to improve the quality of care and patient safety by evaluating the applicability of I-PASS handover in the Child Health Department at Sultan Qaboos University Hospital, Oman.  Results A total of 20 trainees were enrolled in this study. After the implementation of I-PASS, 70% (14/20) of the respondents thought that the handover was well-structured, compared to 30% (6/20) prior to the implementation of I-PASS (P = .003). Due to I-PASS, about 80% of the participants could identify deteriorating patients and around 60% were confident in addressing emergencies. The I-PASS handover technique has raised participants' satisfaction from 80% to 95%. Before I-PASS, the mean adherence rate across all 10 variables was 28.7/50 (57.4%), compared to the post-I-PASS rate of 47/50 (94%). Conclusion The I-PASS system is a feasible and flexible clinical handover tool. This study showed that I-PASS has improved on-call handovers and patient safety.

Improving Handoffs in the Perioperative Environment: A Conceptual Framework of Key Theories, System Factors, Methods, and Core Interventions to Ensure Success

BACKGROUND

Patient handoffs involve the transition of information and responsibility for care from one health care provider to another. They occur frequently during a patient's perioperative care continuum, potentially introducing communication errors that could result in harmful, even fatal consequences. The perioperative environment poses distinct challenges to team communication and patient safety, which in turn leaves the surgical patient uniquely vulnerable to adverse events.

CONCEPTUAL FRAMEWORK

The best way to achieve safe, coordinated handoffs throughout the perioperative continuum has yet to be established. However, a variety of theoretical principles, methods, and interventions have been used successfully in operative and nonoperative contexts among multiple disciplines. Informed by a literature review, the authors describe a conceptual framework for the development, implementation, and sustainment of a multimodal perioperative handoff improvement bundle. The conceptual framework presented here begins with overarching objectives for patient-centered handoff improvement efforts. The article outlines theoretical principles that could be used to guide and inform future multimodal interventions, as well as health care system factors to consider. Further, the authors propose employing data-driven quality improvement and research methodologies to conduct, measure, achieve, and sustain long-term success. Finally, this report describes essential evidence-based interventional components to employ.

IMPLICATIONS

Future efforts to improve handoff safety in the perioperative environment will require a comprehensive evidence-based approach. The authors believe the conceptual framework presented here outlines essential components for success. It integrates proven theoretical frameworks, consideration of system factors, data-driven iterative methods, and synergistic patient-centered interventions.

Implementation of ED I-PASS as a Standardized Handoff Tool in the Pediatric Emergency Department

INTRODUCTION

Communication, failures during patient handoffs are a significant cause of medical error. There is a paucity of data on standardized handoff tools for intershift transitions of care in pediatric emergency medicine (PEM). The purpose of this quality improvement (QI) initiative was to improve handoffs between PEM attending physicians (i.e., supervising physicians ultimately responsible for patient care) through the implementation of a modified I-PASS tool (ED I-PASS). Our aims were to: (1) increase the proportion of physicians using ED I-PASS by two-thirds and (2) decrease the proportion reporting information loss during shift change by one-third, over a 6-month period.

METHODS

After literature and stakeholder review, Expected Disposition, Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver (ED I-PASS) was implemented using iterative Plan-Do-Study-Act cycles, incorporating: trained "super-users"; print and electronic cognitive support tools; direct observation; and general and targeted feedback. Implementation occurred from September to April of 2021, during the height of the COVID-19 pandemic, when patient volumes were significantly lower than prepandemic levels. Data from observed handoffs were collected for process outcomes. Surveys regarding handoff practices were distributed before and after ED I-PASS implementation.

RESULTS

82.8% of participants completed follow-up surveys, and 69.6% of PEM physicians were observed performing a handoff. Use of ED I-PASS increased from 7.1% to 87.5% ( p < .001) and the reported perceived loss of important patient information during transitions of care decreased 50%, from 75.0% to 37.5% ( p = .02). Most (76.0%) participants reported satisfaction with ED I-PASS, despite half citing a perceived increase in handoff length. 54.2% reported a concurrent increase in written handoff documentation during the intervention.

CONCLUSION

ED I-PASS can be successfully implemented among attending physicians in the pediatric emergency department setting. Its use resulted in significant decreases in reported perceived loss of patient information during intershift handoffs.

Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study

BACKGROUND

Handoff miscommunications are a leading source of medical errors. Harmful medical errors decreased in pediatric academic hospitals following implementation of the I-PASS handoff improvement program. However, implementation across specialties has not been assessed.

OBJECTIVE

To determine if I-PASS implementation across diverse settings would be associated with improvements in patient safety and communication.

DESIGN

Prospective Type 2 Hybrid effectiveness implementation study.

SETTINGS AND PARTICIPANTS

Residents from diverse specialties across 32 hospitals (12 community, 20 academic).

INTERVENTION

External teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews.

MAIN OUTCOME AND MEASURES

Systematic surveillance surveys assessed rates of resident-reported adverse events. Validated direct observation tools measured verbal and written handoff quality.

RESULTS

2735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, 3 other) participated. 1942 error surveillance reports were collected. Major and minor handoff-related reported adverse events decreased 47% following implementation, from 1.7 to 0.9 major events/person-year (p < .05) and 17.5 to 9.3 minor events/person-year (p < .001). Implementation was associated with increased inclusion of all five key handoff data elements in verbal (20% vs. 66%, p < .001, n = 4812) and written (10% vs. 74%, p < .001, n = 1787) handoffs, as well as increased frequency of handoffs with high quality verbal (39% vs. 81% p < .001) and written (29% vs. 78%, p < .001) patient summaries, verbal (29% vs. 78%, p < .001) and written (24% vs. 73%, p < .001) contingency plans, and verbal receiver syntheses (31% vs. 83%, p < .001). Improvement was similar across provider types (adult vs. pediatric) and settings (community vs. academic).

Before-After Study of a Checklist to Improve Acute Care to ICU Handoffs

Transferring care of a patient is a critical process. The objective of this study was to evaluate a checklist to standardize handoffs from acute care to the intensive care unit (ICU). This was a single-center, before-after study of a checklist to standardize transfers of patients from acute care to the medical-cardiac ICU. Clinicians completed surveys about handoffs before and after checklist implementation. The association between study period and survey data was analyzed using multivariable logistic regression with cross-classified multilevel models. Surveys were completed by 179 clinicians. After checklist implementation, handoffs were more likely to occur in the ICU (OR 17.23; 95% CI, 1.81-164.19) and cover patient treatment preferences (OR 2.73; 95% CI, 1.12-6.66). However, checklist uptake was suboptimal (30% of responses indicated checklist use). Implementation of a checklist during acute care to ICU transfers is challenging. Signals suggesting process improvement warrant additional study.

Implementation of a standardized handoff system (I-PASS) in a tertiary care pediatric hospital

OBJECTIVE

The handoff is the act of transferring information and responsibility among healthcare providers, and it is critical for the patient safety and the quality of service. The aim of this study was to evaluate the implementation of a standardized medical handoff system [I-PASS (Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver)] and assess the effect on the amount and quality of the information transmitted during medical handoffs in a pediatric ward.

METHODS

In a prospective intervention study, physicians (staff and residents) who work in 12- or 24-h shifts in the pediatric ward of a single tertiary care Brazilian hospital were eligible. Those who agreed to participate were trained in an online session (lecture plus simulation). Medical handoffs were recorded pre- and post-intervention (training) to compare the amount and quality of information transmitted in handoffs.

RESULTS

The handoff standardization significantly increased the number of relevant information delivered for 12 out of the 16 items assessed without increasing, in seconds, the handoff duration (45.9 vs. 48.0; p=0.349). The protocol training and the following discussion about communication resulted in greater focus and attention among participants during transfers, decreasing time spent with interruptions and communication unrelated to the patient (18 vs. 2.7%). Regarding the I-PASS elements, there was an increase in the number of action lists and contingency plans reported (31 vs. 81% and 16 vs. 73%, respectively; p<0.001 for both).

CONCLUSION

Standardization brought greater efficiency and objectivity to handoffs. It increased the quantity and quality of the information transmitted while successfully drawing attention to the most important points.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

Patient safety is the foundation of high-quality health care and remains a critical priority for all clinicians caring for children. There are numerous aspects of pediatric care that increase the risk of patient harm, including but not limited to risk from medication errors attributable to weight-dependent dosing and need for appropriate equipment and training. Of note, the majority of children who are ill and injured are brought to community hospital emergency departments. It is, therefore, imperative that all emergency departments practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This technical report outlined the challenges and resources necessary to minimize pediatric medical errors and to provide safe medical care for children of all ages in emergency care settings.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

This is a revision of the previous American Academy of Pediatrics policy statement titled "Patient Safety in the Emergency Care Setting," and is the first joint policy statement by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association to address pediatric patient safety in the emergency care setting. Caring for children in the emergency setting can be prone to medical errors because of a number of environmental and human factors. The emergency department (ED) has frequent workflow interruptions, multiple care transitions, and barriers to effective communication. In addition, the high volume of patients, high-decision density under time pressure, diagnostic uncertainty, and limited knowledge of patients' history and preexisting conditions make the safe care of critically ill and injured patients even more challenging. It is critical that all EDs, including general EDs who care for the majority of ill and injured children, understand the unique safety issues related to children. Furthermore, it is imperative that all EDs practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This policy statement outlines the recommendations necessary for EDs to minimize pediatric medical errors and to provide safe care for children of all ages.

Contributors to Diagnostic Error or Delay in the Acute Care Setting: A Survey of Clinical Stakeholders

Diagnostic error or delay (DEOD) is common in the acute care setting and results in poor patient outcomes. Many factors contribute to DEOD, but little is known about how contributors may differ across acute care areas and professional roles. As part of a sequential exploratory mixed methods research study, we surveyed acute care clinical stakeholders about the frequency with which different factors contribute to DEOD. Survey respondents could also propose solutions in open text fields. N = 220 clinical stakeholders completed the survey. Care Team Interactions, Systems and Process, Patient, Provider, and Cognitive factors were perceived to contribute to DEOD with similar frequency. Organization and Infrastructure factors were perceived to contribute to DEOD significantly less often. Responses did not vary across acute care setting. Physicians perceived Cognitive factors to contribute to DEOD more frequently compared to those in other roles. Commonly proposed solutions included: technological solutions, organization level fixes, ensuring staff know and are encouraged to work to the full scope of their role, and cultivating a culture of collaboration and respect. Multiple factors contribute to DEOD with similar frequency across acute care areas, suggesting the need for a multi-pronged approach that can be applied across acute care areas.

Effects of an specific methodology (I Pass the Baton) on quality of handoff information among Nurses: A comparative study

AIM

The aim of this study was to investigate the effect of applying I Pass the Baton (IPB) on the quality of handoff among nurses.

METHOD

The present study was a quasi-experimental study. All nurses of the internal wards of Sanandaj educational hospitals, Kurdistan Province, Iran were selected by census method and randomly assigned to intervention (n=34) and control (n=31) groups. Handoff quality was measured by self-report and observation methods. The intervention included a face-to-face training session, training on how to use the IPB, inserting the IPB chart into the patient file, training leaflet, and installing a poster in the ward. The Situation, Background, Assessment, Recommendation (SBAR) was used according to routine practice in the control group. Descriptive and inferential tests were applied to analyze the data using SPSS-16.

RESULTS

The mean score of handoff quality was 82.61±12.77 and 107.11±7.97 before and after the intervention in the intervention group (p<0.05) and 89.00±0.34 and 85.64±19.19 before and after the intervention in the control group, respectively (p=0.91). There was a statistically significant difference between the two groups after the intervention (p<0.05). Implementation of the training program and the IPB tool improved the handoff quality in terms of interaction and support, patient involvement, information quality, and efficiency.

CONCLUSIONS

The IPB has various indicators of patient participation and includes the criteria needed for patient evaluation. Therefore, it can be used to handoff a wide range of patients in the internal ward.

Medical malpractice and gastrointestinal endoscopy

PURPOSE OF REVIEW

Medical liability is a perennial issue that most physicians will face at some point in their careers. Gastroenterologists routinely perform endoscopic procedures to aid in the diagnosis and treatment of their patients. Advances in endoscopic techniques and technology have accelerated movement of the field into a more surgical realm. These developments warrant consideration of pitfalls that may expose gastroenterologists to liability. This review will explore trends in malpractice facing gastroenterologists and offer strategies to deliver high quality and safe patient care.

RECENT FINDINGS

Despite being a procedure-oriented subspeciality, only a minority of malpractice claims against gastroenterologists are related to procedures. Diagnostic error is among the most prevalent reason for lawsuits. The consequences of malpractice are costly due litigation and indemnity as well as the increase in defensive medical practice. Improving diagnostic quality, optimizing informed consent, and enhancing patient-physician communication are important elements of risk mitigation.

SUMMARY

Understanding the important role that diagnosis plays in medical liability allows physicians to better evaluate risk and apply deliberate decision-making in order to practice confidently.

Sustained Improvement in Quality of Patient Handoffs After Orthopaedic Surgery I-PASS Intervention

The I-PASS tool has been shown to decrease medical errors in patient handoffs in nonorthopaedic surgery fields. We prospectively studied the implementation of a version of this handoff tool modified for orthopaedic surgery patients in an academic practice at two level I trauma centers.

Emerging Professional Identity in Patient Hand-Off Routines: A Practical Application of Performative Face Theory

Recent research of healthcare providers identifies the critical role that professional identity plays in the provision of healthcare, interactions within healthcare teams, and healthcare provider perceptions of their work. However, much remains to be known regarding the role of professional identity in routine interactions for emerging healthcare professionals. This study enriches understandings of this particular issue by exploring pediatric residents' experiences with a structured hand-off tool at a children's hospital in the western United States. This study employed qualitative interview methods and iterative interpretive qualitative data analysis. Participants were 20 residents in a children's hospital. Data analysis indicated that the discourses that disseminate negotiations of face can, and often do, take place during patient hand-off, as the statements exchanged between team members can maintain or threaten face and professional identity. We suggest that shifts in organizational culture and training are necessary to optimize the environment in which residents use structured hand-off. Further, the culture and practice of training emerging physicians should include attention to the important role of hand-off as a critical site of professional identity construction and negotiation.

I-PASS enhances effectiveness and accuracy of hand-off for pediatric general surgery patients

BACKGROUND

I-PASS is a validated and standardized hand-off protocol shown to reduce medical error and improve hand-off efficiency in the pediatric medical population. Our aim was to evaluate the feasibility, effectiveness, accuracy and resident satisfaction of implementing I-PASS on a pediatric surgery service.

METHODS

A prospective intervention Quality Improvement (QI approved) study was utilized to evaluate resident written and verbal hand-offs before and after implementation of I-PASS on a pediatric surgery service at a tertiary center. Anonymous surveys were completed by residents following each observation. Results were analyzed using T or Mann-Whitney U Tests and Chi Square.

RESULTS

A total of 49 written tools and 50 verbal hand-offs were compared pre-and post I-PASS implementation. With I-PASS, increased written accuracy was observed in the documentation of the patient summary (p < 0.05). Accuracy in the verbal hand-off of illness severity, patient summary, contingency plan, action list and synthesis also improved (p < 0.05); but duration of hand-off increased (p < 0.01). Post implementation surveys of residents demonstrated an increased understanding of patient management (p < 0.05).

CONCLUSION

Implementing I-PASS on a pediatric surgery service with modifications catered to surgical patients, improved the effectiveness and accuracy of written and verbal patient hand-offs and increased provider satisfaction and preparedness.

LEVEL OF EVIDENCE

Level II.

Effect of a Multispecialty Faculty Handoff Initiative on Safety Culture and Handoff Quality

Structured handoffs at transitions of care are vital components of patient safety. A safety culture survey showed that “handoffs and transitions” were among the lowest scoring dimensions at our hospital. We sought to improve physician handoffs and safety culture scores by implementing standardized handoff communication across multiple divisions of an academic pediatric department.

Optimizing the Orthopaedic Consult

Providing orthopaedic call coverage is a core requirement for orthopaedic surgery residents. Developing proper call habits and routines during residency is critical to becoming an attending surgeon who provides high-quality call coverage and consultations without difficulty. Although patient acuity and call duration and frequency may vary among rotations and hospitals, the fundamentals remain the same. Because personal health and content knowledge are critical for success, physical and mental preparation is done in advance. Using a stepwise approach for answering calls, taking a history, performing a physical examination, interpreting studies, and performing procedures can improve the quality and efficiency of patient care. Standard practices can be used to improve the process of scheduling urgent and emergent surgery or establishing outpatient follow-up. When the complexity or volume of patient care exceeds one's capabilities, it is critical to know when and how to ask for help. Clear communication is essential for safe and effective transitions of care and when presenting patients to attending surgeons. A call shift can also serve as a learning experience by reading on topics as each consult is completed, teaching others, and following up on patient outcomes after the call shift.

Improving Transfer of Care Between Psychiatrists and Residents: Participants' Perspective on the Implementation of a Handover Protocol in a Psychiatric Emergency

OBJECTIVES

Handover refers to the transfer of information from one professional to another during transitions of care. I-PASS is a mnemonic tool which stands for Illness severity; Patient summary; Action list; Situation awareness and contingency planning; and Synthesis by receiver. It was developed to standardize the handover process. Psychiatrists, nurses, and residents at the Montreal Jewish General Hospital psychiatric emergency were trained and the I-PASS handover model was implemented.

METHODS

Thirty-one psychiatrists, nurses, and residents participated in this quality improvement project. Participants filled a pre-training questionnaire to examine the baseline status of handovers before attending a training session on I-PASS. Participants then filled a second questionnaire assessing the perceived quality of the handover training session, as well as anticipated benefits and challenges of I-PASS prior to its implementation. Finally, following implementation, two focus groups were held to collect feedback from participants.

RESULTS

Pre-training, most participants reported that information provided during handovers was incomplete. Training was overall much appreciated. The most significant anticipated obstacle for implementing I-PASS was lack of time to properly fill out the form. Post-implementation, participants unanimously reported an improvement in the handover process. Handovers were perceived as faster, providing all key information about patients, and the perceived quality of the information was better.

CONCLUSION

Overall, the implementation of the I-PASS handover model was much appreciated by participants, who perceived that handovers were more comprehensive, efficient, and of better quality.

A Human Factors Approach to Vaginal Retained Foreign Objects

STUDY OBJECTIVE

To apply a structured human factors analysis to understand conditions contributing to vaginal retained foreign objects (RFO).

DESIGN

All potential vagina RFO events from January 1, 2000, to May 21, 2019, were analyzed by trained human factors researchers. Each narrative was reviewed to identify contributing factors, classified using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare).

SETTING

An 890-bed, academic medical center in Southern California.

PATIENTS

Patients who underwent a vaginal procedure in which a vaginal RFO-related event occurred were included in this study. However, no patient information was included, only the relevant details from their procedures.

INTERVENTIONS

No interventions were developed or implemented.

MEASUREMENTS AND MAIN RESULTS

Over the 19-year period, 45 events were reported. The most common items were vaginal packing and vaginal sponges (53.33%).  Less frequently retained items involved broken instruments (20.20%).  The majority of cases were laparoscopic hysterectomies or vaginal deliveries.  Based on HFACS, 75 contributing factors were identified, consisting primarily of preconditions for unsafe acts (communication challenges, coordination breakdowns and issues with the design of tools/technology) and unsafe acts (errors).

CONCLUSION

While rare, vaginal RFOs do occur. The top two contributing factors were skill-based errors and communication breakdowns. Both types of errors can be addressed and improved with human factors interventions, including simulation, teamwork training, and streamlining workflow to reduce the opportunity for errors.

Physician-to-Nurse Handover: A Systematic Review on the Effectiveness of Different Models

OBJECTIVES

Effective professional communication and accurate transfer of relevant clinical information are crucial components of healthcare delivery. National and international health authorities strongly recommend the adoption of effective handover practice. Still, scant evidence is available on the impact of different multiprofessional handover models.

METHODS

We carried out a systematic review following the Prepared Items for Systematic Reviews and Meta-Analysis guidelines to retrieve, pool, and critically appraise the available evidence on the effectiveness of different physician-to-nurse handover models adopted in inpatient settings.

RESULTS

We identified 1.243 citations searching the databases Medline, Embase, and CINAHL. After screening, 10 studies were included in the review reporting results on the effectiveness of 8 different handover models, measured on 44 different outcomes, grouped into: (1) process of care and efficiency outcomes, (2) patients' outcomes, and (3) healthcare professionals-related outcomes. Overall, applying structured handover tools improve healthcare practice and selected outcomes; however, not only solid evidence on the effectiveness of different handover models is scant but also global consensus is lacking on which standardized measures and indicators to use to assess their impact.

CONCLUSIONS

In times of healthcare delivery models of growing complexity, multiprofessional handover is a key component of care paths. Although there is overall consensus on the need for improving the quality and safety of multiprofessional handover, the evidence on the tools available to achieve it and the metrics to measure their impact is heterogeneous. We urge that rigorous studies are conducted to inform the planning, implementation, and monitoring of effective handover, with the ultimate aim of improving quality of care and patient safety.

For Residents, by Residents: Developing a Physician Handoff Tool at a University Affiliated Community Hospital

The 80-hour per week work limit resulted in an increased number of patient handoffs. A satisfactory handoff system should optimize the exchange of vital patient information while concisely minimizing error. This project describes our experience and lessons learned in successfully developing and implementing an Electronic Health Record (EHR)-integrated handoff system based on the I-PASS model. The handoff system, termed Physician Handoff, was refined through end-user feedback. End-users were evaluated on the quality of handoff in the following categories: Illness Severity, Patient Summary, Action List, and Situational Awareness. Resulting survey showed high adoption and satisfaction rate with Physician Handoff. Success can be attributed to interdepartmental collaboration, credentialing the users, and recognizing the importance of end-user feedback.

Improving Communication for Admissions From Urgent Care to Inpatient Using a Structured Handoff

BACKGROUND

Previous studies reveal that ineffective communication contributes to patient-safety events. Structured handoffs improve communication during shift change and transfers from outpatient clinics to emergency departments. We aimed to improve the perceived quality of admission handoffs from a baseline of 22.2% to 50% by the end of the study period through use of a standardized template between urgent care (UC) and inpatient providers.

METHODS

We used quality improvement methodology to identify key themes (clarity in illness severity, organization, completeness, and pace) that contribute to decreased quality communication. A survey to evaluate the perception of communication and key themes between the groups was administered. During the 15-month quality improvement study at a tertiary pediatric institution, we implemented a handoff tool with visual aids. Givers of information received formal training. Participants received iterative performance feedback. A control chart was used to monitor fidelity to the handoff tool. We used statistical analyses to compare changes in perceived communication between provider types before and after implementation of the handoff tool.

RESULTS

Both UC and inpatient providers had an increased rate of positive perceptions in the overall quality of communication after 12 months of using the admission handoff tool (22% vs 67.3%; P = .01). Complete fidelity to the admission handoff tool increased over time. There was no change in mean duration of handoff (4 minutes) after implementing the structured handoff.

CONCLUSIONS

A structured handoff during admission of pediatric patients from an off-site UC to inpatient setting improved the perception of the quality of admission handoff communication.

Entrustable professional activities framework for assessment of patient handoffs in dentistry

PURPOSE/OBJECTIVES

The aim of this study is to report data on the lack of a proper patient handoff system in dentistry and dental education and to present a possible solution to integrate this into curriculum using the "entrustable professional activities" (EPAs) framework.

METHODS

Delphi participants from seven US dental schools provided feedback on a preliminary definition of handoff, a mnemonic and an assessment rubric. 2019 American Dental Education Association Commission on Change and Innovation in Dental Education (ADEA CCI) participants further evaluated the handoff EPA using the EQual rubric for EPA quality and structure.

RESULTS

Delphi participants identified points of transition in dentistry, selected the D-PASS as a mnemonic, and agreed with the evaluation rubric. The ADEA CCI participants agreed the handoff EPA describes work that is essential for the profession and suitable for entrustment.

CONCLUSION

The D-PASS rubric is an effective way to assess patient handoffs.

The recent evolution of patient care rounds in pediatric teaching hospitals in the United States and Canada

Introduction: National trends toward empowering and enabling patients and families to take a bigger role in their own medical care and enhanced collaboration between rounding stakeholders have effectuated a new rounding model in the pediatric inpatient setting known as 'Patient- and Family-Centered Rounds/I-PASS,' which has shown to decrease safety events and to improve stakeholders' experience with rounding. Other enhancements to the new model, such as the use of whiteboards, rounding checklists, and facecards, have all been applied to the new model to good effect. Another major enhancement to rounding of late has been the application of a schedule to rounds, which has increased the presence of the nurse and the family during rounds and has improved rounding efficiency without a negative effect on teaching.Objective:  We provide a review of the literature regarding this new rounding model and its effects in the pediatric inpatient setting, as well as a review of the enhancements that have been applied to the new model, the recognized barriers to the implementation of these rounding alterations and the ways in which those barriers have been overcome. Conclusions:  In the pediatric inpatient setting, the 'Patient and Family-Centered Rounds/IPASS' rounding model, as well as enhancements to this new model such as rounding schedules, whiteboards, checklists and facecards, have had a positive effect on stakeholders' experience with rounding, increased patient safety and improved rounding efficiency.  Given these positive effects, these alterations to rounding should be promoted and sustained.PLAIN LANGUAGE SUMMARYRounding is when a medical care provider, or a team of providers, visits patients in the hospital in order to determine a plan of care and discuss that care with the patient and the patient's family. In teaching hospitals, this involves staff physicians, medical trainees and advanced practice providers. Rounding has changed in the recent past as evolving pressures have increasingly led these teams of providers to talk and make decisions about patients outside the patient's room, which lessens the patient's ability to contribute to decision-making. This also lessens the ability of the patient's nurse to contribute. The recognition of this problem has led to big changes in rounding in children's teaching hospitals, the biggest of which is called 'family-centered rounding.' This involves performing the entirety of rounds in the patients' rooms, directing the discussion toward them in language that they understand, with the active participation of everyone present, including the patient's nurse. Other changes in rounding, designed to improve patients' experiences and decrease medical errors, have made this new rounding model even better. Structured communication during rounds, communication aids such as whiteboards and checklists, and planned times for rounding on each patient ('scheduled rounding') have all successfully been used to improve patients' care and experience in the hospital. This article aims to inform the reader about family-centered rounds and other recent rounding transformations that have proven to increase patient safety and improve their experience while in the hospital, also noting barriers to these changes and how they have been overcome.

A SWIFT Method for Handing Off Obstetrical Patients on the Labor Floor

OBJECTIVE

The aim of this study was to improve patient handoffs on the labor floor.

METHODS

A prospective cohort study of obstetrics residents at Montefiore Medical Center was performed between 2012 and 2014. Labor-floor handoffs were recorded before and after didactic sessions as well as after installation of whiteboards formatted with the mnemonic SWIFT (Subject, Why?, Issues, Fetus, Tasks). Handoff transcripts were evaluated by obstetricians blinded to timing and speaker identity. An intraclass correlation coefficient accounted for evaluator differences. Data analysis was by ordinal logistic regression, the generalized estimating equations method (correlated data), and Bonferroni adjustment (multiple comparisons).

RESULTS

Forty-five handoffs were evaluated (15 each predidactics, postdidactics, and postwhiteboard revision). Higher completeness scores over time were noted for admission reason, labor concerns, and task list (not statistically significant). Comprehensive score increases prelecture to postwhiteboard were seen in handoff clarity (2.81 versus 2.91) and overall quality (2.77 versus 2.81) (not statistically significant). A subanalysis of four residents who gave multiple handoffs over different periods revealed few significant changes over time. Greater interevaluator consistency was noted with more objective elements.

CONCLUSIONS

The mnemonic SWIFT, with formalized curricula for obstetrical resident training focusing on new learners and increased faculty involvement and reinforcement, may result in improvement of handoffs on the labor floor.

Factors Related to Serious Safety Events in a Children's Hospital Patient Safety Collaborative

BACKGROUND AND OBJECTIVES

Serious safety events (SSEs) occur infrequently at individual hospitals, making it difficult to establish trends to improve patient care. Patient safety organizations, such as the Child Health Patient Safety Organization (CHILDPSO), can identify trends and support learning across children's hospitals. We aim to describe longitudinal trends in SSE rates among CHILDPSO member hospitals and describe their sources of harm.

METHODS

SSEs from 44 children's hospitals were assigned severity and reported to CHILDPSO from January 1, 2015, to December 31, 2018. SSEs were classified into groups and subgroups based on analysis. Events were then tagged with up to 3 contributing factors. Subgroups with <5 events were excluded.

RESULTS

There were 22.5 million adjusted patient days included. The 12-month rolling average SSE rate per 10 000 adjusted patient days decreased from 0.71 to 0.41 (P < .001). There were 830 SSEs reported to CHILDPSO. The median hospital volume of SSEs was 12 events (interquartile range: 6-23), or ∼3 SSEs per year. Of the 830 events, 21.0% were high severity (SSE 1-3) and approximately two-thirds (67.0%, n = 610) were patient care management events, including subgroups of missed, delayed, or wrong diagnosis or treatment; medication errors; and suboptimal care coordination. The most common contributing factor was lack of situational awareness (17.9%, n = 382), which contributed to 1 in 5 (20%) high-severity SSEs.

CONCLUSIONS

Hospitals sharing SSE data through CHILDPSO have seen a decrease in SSEs. Patient care management was the most frequently seen. Future work should focus on investigation of contributing factors and risk mitigation strategies.

Usability Assessment of an Electronic Handoff Tool to Facilitate and Improve Postoperative Communication Between Anesthesia and Intensive Care Unit Staff

The handoff or handover is the exchange of pertinent medical information from one provider to another. Inadequate handoff communication between healthcare providers can negatively impact patient outcomes. In an effort to improve handoff communication, many studies have developed and evaluated the use of a handoff tool such as a handoff checklist or handoff form to facilitate handoff communication. Recently, the use of the IPASS handoff form, based on the mnemonic for the process, has been associated with a reduction in the rate of adverse events and improvement in information transfer and nurse satisfaction. This quality improvement project adapted the IPASS handoff form for postoperative use in an iterative approach over a series of four phases: (1) requirements/information gathering, (2) adaptation/development, (3) evaluation and modification, and (4) usability testing. Results of this project show that participants viewed the postoperative IPASS handoff form to be easy to use (87.5%), satisfactory (75.0%), and user-friendly (75.0%), which can facilitate its widespread adoption. The key feature identified in making the handoff form user-friendly was its customization feature, which allowed the handoff report to be shortened or expanded to meet the provider- or unit-specific needs.

The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS

BACKGROUND AND OBJECTIVES

Despite the American College of Emergency Physicians and American Academy of Pediatrics recommendations for standardised handoffs in the emergency department (ED), few EDs have an established tool. Our aim was to improve the quality of handoffs in the ED by establishing compliance with the I-PASS handoff tool.

METHODS

This is a quality improvement (QI) initiative to standardise handoffs in a large academic paediatric ED. Following review of the literature and focus groups with key stakeholders, I-PASS was selected and modified to fit departmental needs. Implementation throughPlan-Do-Study-Act cycles included the development of educational materials, reminders and real-time feedback. Required use of I-PASS during designated team sign-out began in June 2016. Compliance with the handoff tool and handoff deficiencies was measured through observations by faculty trained in I-PASS. As a balancing measure, time to complete handoff was monitored and compared with preintervention data.

RESULTS

Compliance with I-PASS reached 80% within 6 months, 100% within 7 months and sustained at 100% during the remainder of the study period. The average percent of omissions of crucial information per handoff declined to 8.3%, which was a 53% decrease. Average percentage of tangential information and miscommunications per handoff did not show a decline. The average handoff took 20 min, which did not differ from the preintervention time. Survey results demonstrated a perceived improvement in patient safety through closed-loop communication, clear action lists and contingency planning and proper patient acuity identification.

CONCLUSIONS

I-PASS is applicable in the ED and can be successfully implemented through QI methodology contributing to an overall culture of safety.

A Quality Education: A Comprehensive Review of a Combined Longitudinal and Specialty Track Quality Improvement and Patient Safety Medical School Curriculum

Structured quality improvement and patient safety (QI/PS) education has increased at every level of medical education; however, great variability exists in the content taught. Here, the authors present a longitudinal model for medical student QI/PS education that is currently implemented at the University of Florida College of Medicine. The curriculum is taught with a variety of teaching methods incorporated into each year with increasing levels of clinical implementation. This curriculum is multimodal and introduces students to QI/PS concepts, presents mock scenarios, and eventually encourages clinical application to situations students experience during their own clinical practice. Additionally, a specialized track for students to have further immersion into this field of medicine is described, which involves specialized training, expanded educational opportunities, and a capstone project. Both the curriculum and specialized track contain explicit clinical integration to ensure students are prepared to enter the medical profession to engage in QI/PS endeavors.

Handoffs in Radiology: Minimizing Communication Errors and Improving Care Transitions

Handoffs are essential to achieving safe care transitions. In radiology practice, frequent transitions of care responsibility among clinicians, radiologists, and patients occur between moments of care such as determining protocol, imaging, interpreting, and consulting. Continuity of care is maintained across these transitions with handoffs, which are the process of communicating patient information and transferring decision-making responsibility. As a leading cause of medical error, handoffs are a major communication challenge that is exceedingly common in both diagnostic and interventional radiology practice. The frequency of handoffs in radiology underscores the importance of using evidence-based strategies to improve patient safety in the radiology department. In this article, reliability science principles and handoff improvement tools are adapted to provide radiology-focused strategies at individual, team, and organizational levels with the goal of minimizing handoff errors and improving care transitions.

Evaluation of Consecutive Guided Training to Improve Interrater Agreement in Identifying Elements of Situation Awareness in Objective Structured Clinical Examination Assessments

This article was migrated. The article was marked as recommended. Introduction: Little is known about the medical student's cognitive ability in diagnostic and therapeutic accuracy. Literature does not suggest a methodology to quantify students' cognitive processing. Situation Awareness (SA) is described as having the proficiency to obtain awareness of the surrounding and to integrate this consciousness into the situational context and potential forthcoming development. OSCEs might be a suitable instrument to evaluate students' awareness of the situation. Methods: Consecutive guided training was provided to obtain a consistent comprehension of the model of SA. 4 independent researchers consecutively examined 6 randomised OSCE forms in a qualitative and quantitative method. Final interrater agreement was expressed as Cohens kappa. Generalisability theory determined the impact of the main facets on the variation in disagreement. Results: Evaluation of identifying and categorising elements of SA within OSCE forms demonstrated a moderate to very good interrater agreement. The G-Theory revealed key facets for variance: OSCE forms, Levels of SA, Items embedded in the Levels, Interaction between Forms and Levels and Forms and Items embedded within Levels. Conclusion: Consecutive guided training improved the identification of elements of SA within OSCE assessments. Further research is necessary to improve the assessment of SA in undergraduate medical curricula.