Transitions of care – more frequent now in medicine than ever before – are fertile opportunities for error and miscommunication. Most institutions have developed, at least, informal protocols to exchange patient information during hand-off. But, certainly, everyone has some anecdotal tale of missed information leading to a near-miss or actual patient harms.
This study tells the story of I-PASS, a handoff bundle implemented and measured as an error prevention strategy by a pre- and post-intervention study design. Across 9 pediatric residency training programs, residents were observed for six months for time spent in hand-offs, time spent in patient care, and a variety of classifications of preventable and non-preventable errors. Then, the I-PASS bundle was introduced – a structured sign-out mnemonic, a 2-hour workshop on communication skills, a 1-hour role-playing and simulation intervention, a faculty development program, direct-observation tools, and a culture-change campaign with a logo, posters, and other promotional activities.
Following the intervention, residents were, again, observed for six-months. And, in general, preventable medical errors decreased a small absolute amount, along with a larger absolute decrease in near misses. 2 of 9 hospitals had increases in medical errors after the interventions, and the bulk of the effect size was a result of improvements at two hospitals whose baseline error rate was double that of the other 7 facilities.
The authors, then, are very excited about their I-PASS bundle. But, as they note at the end of their discussion: “Although bundling appears to have been effective in this instance, it prevents us from determining which elements of the intervention were most essential.” And, on face validity, this is obvious – the structured sign-out sheet was only one of many quality improvement interventions occurring simultaneously. A decisive change in culture will trump the minor components of implementation anytime.
The final takeaway: if your institutional audit reveals handoff-related errors are pervasive and troublesome, and if reductions in such errors are prioritized and supported with the correct resources, you will probably see a reduction. The I-PASS tool itself is not important, but the principles demonstrated here probably are.
“Changes in Medical Errors after Implementation of a Handoff Program”
http://www.ncbi.nlm.nih.gov/pubmed/25372088