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Original Investigation |

Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle

Amy J. Starmer, MD, MPH1 ,2; Theodore C. Sectish, MD1 ; Dennis W. Simon, MD1 ,3; Carol Keohane, RN4; Maireade E. McSweeney, MD, MPH1 ; Erica Y. Chung, MD1 ,5; Catherine S. Yoon, MS4; Stuart R. Lipsitz, PhD4; Ari J. Wassner, MD1 ; Marvin B. Harper, MD1 ; Christopher P. Landrigan, MD, MPH1 ,4
[+] Author Affiliations
1 Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
2Doernbecher Children’s Hospital, Oregon Health and Science University, Portland
3Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
4Divisions of General Internal Medicine and Sleep Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
5Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence
JAMA. 2013;310(21):2262-2270. doi:10.1001/jama.2013.281961.
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Importance  Handoff miscommunications are a leading cause of medical errors. Studies comprehensively assessing handoff improvement programs are lacking.

Objective  To determine whether introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events, fewer omissions of key data in written handoffs, improved verbal handoffs, and changes in resident-physician workflow.

Design, Setting, and Participants  Prospective intervention study of 1255 patient admissions (642 before and 613 after the intervention) involving 84 resident physicians (42 before and 42 after the intervention) from July-September 2009 and November 2009-January 2010 on 2 inpatient units at Boston Children’s Hospital.

Interventions  Resident handoff bundle, consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure. On one unit, a computerized handoff tool linked to the electronic medical record was introduced.

Main Outcomes and Measures  The primary outcomes were the rates of medical errors and preventable adverse events measured by daily systematic surveillance. The secondary outcomes were omissions in the printed handoff document and resident time-motion activity.

Results  Medical errors decreased from 33.8 per 100 admissions (95% CI, 27.3-40.3) to 18.3 per 100 admissions (95% CI, 14.7-21.9; P < .001), and preventable adverse events decreased from 3.3 per 100 admissions (95% CI, 1.7-4.8) to 1.5 (95% CI, 0.51-2.4) per 100 admissions (P = .04) following the intervention. There were fewer omissions of key handoff elements on printed handoff documents, especially on the unit that received the computerized handoff tool (significant reductions of omissions in 11 of 14 categories with computerized tool; significant reductions in 2 of 14 categories without computerized tool). Physicians spent a greater percentage of time in a 24-hour period at the patient bedside after the intervention (8.3%; 95% CI 7.1%-9.8%) vs 10.6% (95% CI, 9.2%-12.2%; P = .03). The average duration of verbal handoffs per patient did not change. Verbal handoffs were more likely to occur in a quiet location (33.3%; 95% CI, 14.5%-52.2% vs 67.9%; 95% CI, 50.6%-85.2%; P = .03) and private location (50.0%; 95% CI, 30%-70% vs 85.7%; 95% CI, 72.8%-98.7%; P = .007) after the intervention.

Conclusions and Relevance  Implementation of a handoff bundle was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children. Improvements in verbal and written handoff processes occurred, and resident workflow did not change adversely.

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Figure.
Percentage of Written Handoff Documents That Included Key Data Elements

aThe unit 1 intervention consisted of a resident handoff bundle that included a computerized handoff tool.bThe unit 2 intervention consisted of a resident handoff bundle that did not include a computerized handoff tool.

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