Changes in Medical Errors after Implementation of a Handoff Program¶
Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., Noble, E. L., et al. (2014). Changes in Medical Errors after Implementation of a Handoff Program. New England Journal of Medicine, 371(19), 1803-1812.
Cited by¶
4 citations across 4 artifacts.
Each citation links to the sentence it supports in the citing article.
Domain-specific¶
- Handoff Loss
- In a large multi-center study of pediatric residency programs (Starmer et al., 2014), implementing I-PASS was associated with a substantial fall in medical errors and preventable adverse events, with no loss of workflow efficiency.
This sourceA nine-hospital handoff-program study reporting a 23% fall in medical errors and a 30% fall in preventable adverse events without a workflow penalty.
Supported in partVerified against the publisher's abstract
“the medical-error rate decreased by 23% from the preintervention period to the postintervention period”
- In a large multi-center study of pediatric residency programs (Starmer et al., 2014), implementing I-PASS was associated with a substantial fall in medical errors and preventable adverse events, with no loss of workflow efficiency.
Mechanisms¶
- Handoff Checkback
- At 7 a.m. shift change, an emergency-department nurse hands four patients to the incoming nurse using a structured checkback in the spirit of the I-PASS handoff bundle
This sourceEvaluates the I-PASS bundle as a standardized program for change-of-shift patient handoffs.
- At 7 a.m. shift change, an emergency-department nurse hands four patients to the incoming nurse using a structured checkback in the spirit of the I-PASS handoff bundle
- Shift Handoff Briefing
- Structured clinical handoff tools such as I-PASS and SBAR
This sourceA structured I-PASS handoff program improved communication and was associated with fewer medical errors.
- Structured clinical handoff tools such as I-PASS and SBAR
- Situation Handoff Report
- Structured handoff protocols with read-back are among the better-evidenced interventions against exactly this seam.
This sourceReports that implementing the structured I-PASS handoff program reduced medical errors without increasing handoff duration.
- Structured handoff protocols with read-back are among the better-evidenced interventions against exactly this seam.
Verification¶
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