The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
I-PASS is a structured handoff tool to enhance communication during patient transfers and improve patient safety. This study found that I-PASS implementation at 32 hospitals decreased major and minor handoff-related adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across provider types and settings.
Patients and families represent an often untapped resource in identifying errors and adverse events. Using a mobile health tool, pediatric patients and families were encouraged to report safety events that occurred during the child’s hospital stay. These reports were compared with incident reports (IRs) submitted to the internal incident reporting system. Of the 51 potential IR observations, only one had been submitted to the IR system. Notably, differences in the number of reported events varied by race, ethnicity, insurance status, and other marginalized groups, highlighting a need to explicitly engage these populations.
O'Toole JK, Starmer AJ, Calaman S, et al. MedEdPORTAL. 2019;15:10794.
Champions play critical roles for implementing change in organizations. This commentary reports the results of a program to train champions of the I-PASS handoff program. The initiative used a set of tools and educational tactics to build frontline leaders' skills to mentor standardized handoffs behaviors at 32 locations. The process and tools were considered by participants as instrumental in the success of leading staff to adopt I-PASS techniques at the institutions.
O'Toole JK, Starmer AJ, Calaman S, et al. MedEdPORTAL. 2018;14:10736.
The I-PASS structured handoff tool intends to reduce errors and preventable adverse events. This article describes the development of the I-PASS Mentored Implementation Guide. The guide was considered by I-PASS sites essential, particularly the sections on the I-PASS curriculum and handoff observations.
Khan A, Spector ND, Baird JD, et al. BMJ. 2018;363:k4764.
Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of Patient and Family Centered (PFC) I-PASS rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.
Early in the academic year, interns were on their first day of a rotation caring for an elderly man hospitalized for a stroke, who had developed aspiration pneumonia and hypernatremia. When the primary intern signed out to the cross-cover intern, he asked her to check the patient's sodium level and replete the patient with IV fluids if needed. Although the cross-covering intern asked for more clarification, the intern signing out assured her the printed, written signout had all the information needed.
Chacko KM, Halvorsen AJ, Swenson SL, et al. Am J Med Qual. 2018;33:405-412.
Engaging trainees in quality improvement efforts has been an important area of focus within graduate medical education, but less is known about how health system resources are aligned with these activities. Researchers used survey data to better understand the perceptions of internal medicine residency program directors regarding health system support for and alignment with graduate medical education quality improvement efforts.
Rosenbluth G, Destino LA, Starmer AJ, et al. Ped Qual Saf. 2018;3:e088.
Patient handoffs carry high risk for errors. I-PASS is a structured handoff tool that reduces errors and preventable adverse events. Investigators noted that substantial culture change was required to implement I-PASS in the nine hospitals in which it was initially studied. In this study, they describe the organizational transformation techniques that fostered widespread I-PASS adoption. Tangible elements included establishing a sense of urgency, developing a memorable multimedia campaign, and engaging health care system and educational leaders. Their successes and lessons learned may provide a roadmap for implementing other evidence-based safety campaigns at academic centers. Two WebM&M commentaries explore the risks of handoffs and how to mitigate them. A PSNet interview discussed handoffs and the implementation and findings of the landmark I-PASS study.
Myers JS, Tess A, McKinney K, et al. J Grad Med Educ. 2017;9:9-13.
It is critical to educate trainees about patient safety. In this study, researchers described lessons learned from creating a leadership role that bridges quality and safety activities with graduate medical education in each of their institutions. Key responsibilities included clinical oversight, faculty development, and educational innovation. The authors advocate for further evaluation of this safety and education leadership role to determine its impact on medical education and patient outcomes.
Khan A, Coffey M, Litterer KP, et al. JAMA Pediatr. 2017;171:372-381.
Detecting adverse events remains a challenge across health care settings. This prospective study conducted in multiple pediatric inpatient settings used medical record review, clinician reports, and hospital incident reports to identify adverse events. Investigators compared adverse events detected with these mechanisms to adverse events identified through interviews with parents and caregivers of pediatric patients. As with previous studies, two physicians reviewed all incidents and rated the severity and preventability of all incidents. About half the incidents reported by family members were determined to be safety concerns; fewer than 10% of these incidents were felt to be preventable adverse events. Family-reported error rates were similar to error rates drawn from actively eliciting error reports from clinicians. Families were able to identify preventable adverse events that were not detected by any other method. Error rates calculated from hospital incident reports were much lower than those drawn from either clinician or family reports, consistent with prior studies. These results demonstrate that families can identify otherwise undetected adverse events and their input should be elicited in safety surveillance systems.
Rosenbluth G, Landrigan CP. Pediatr Clin North Am. 2012;59:1317-28.
Fatigue can lead to poor performance and diminished safety in high-risk industries. This review discusses the literature exploring how sleep deprivation affects clinician performance and the impact of work hour limits as a strategy to address the problem. The authors provide suggestions to redesign work schedules to improve handoffs and other processes affected by work hour restrictions.
Rosenbluth G, Jacolbia R, Milev D, et al. BMJ Qual Saf. 2016;25:324-8.
Despite advances in handoff practices, printed signout documents remain ubiquitous in inpatient settings. This chart review study found that the accuracy of printed signout sheets decline significantly over the course of a physician shift. This work highlights the need for more real-time updated patient information than a printed page can provide.
Tess A, Vidyarthi A, Yang J, et al. Acad Med. 2015;90:1251-7.
Engaging residents and fellows in quality and safety programs is a recognized strategy to address a gap in medical education. This commentary describes a six-factor framework to integrate safety concepts into graduate medical education curriculum focusing on organizational elements such as culture, interprofessional learning, and faculty development.
Significant progress has been made in preventing errors at the time of handoffs between clinicians. As demonstrated in the landmark I-PASS study, patient safety can be improved by implementation of a standard format for verbal handoffs. This study—performed by the I-PASS study investigators—examined the quality of written signout documents, which are used by overnight covering physicians to complement the verbal signout. Written signouts were not standardized in either structure or content, and they frequently lacked information elements (such as illness severity) that are considered essential for a high-quality signout. Based on these findings, the authors make recommendations for the core data elements for written signouts. A case of a delayed diagnosis due to inadequate signout is discussed in a previous AHRQ WebM&M commentary.
Starmer AJ, Spector ND, Srivastava R, et al. New Engl J Med. 2014;371:1803-1812.
The number of handoffs a patient experiences while hospitalized has almost certainly increased at academic institutions after the implementation of duty hour restrictions, posing a significant threat to patient safety. In response, The Joint Commission required that all hospitals maintain a standardized approach to handoff communication, and in 2010 the Accreditation Council for Graduate Medical Education required that all residents receive formal handoff training. This multicenter study demonstrates that implementation of a standardized handoff bundle—which included a mnemonic ("I-PASS") for standardized oral and written signouts, formal training in handoff communication, faculty development, and efforts to ensure sustainability—was associated with a 23% relative reduction in the incidence of preventable adverse events across 9 participating pediatric residency programs. This improvement was achieved through a very high level of resident engagement in the revised handoff process, but did not negatively affect resident workflow. This rigorously designed and analyzed study establishes the I-PASS model as the gold standard for effective clinical handoffs and demonstrates the value of methodologically stringent approaches to addressing patient safety issues. A case of a delayed diagnosis due to poor handoffs is discussed in a past AHRQ WebM&M commentary.
Williams M, Li J, Hansen LO, et al. South Med J. 2014;107:455-65.
This qualitative study of a large-scale quality improvement effort to reduce readmissions and adverse events after discharge identified numerous barriers to implementing the project as well as several facilitators of success. Intensive mentoring by project champions appeared to be a key factor in success of the program.
This study describes the process of developing I-PASS, a standardized curriculum for improving the quality of signouts, along with preliminary outcomes and lessons learned. Early studies show that I-PASS is associated with a reduction in signout errors among resident physicians.
Kaiser S, Asteria-Peñaloza R, Vittinghoff E, et al. Pediatrics. 2014;133:e1139-47.
Codeine is considered a high-risk medication in children due to variability in its metabolization. Despite recommendations against its use, this analysis of national data over a 10-year period found only a slight decrease in codeine prescriptions for children seen in the emergency department.
Vidyarthi A, Green AL, Rosenbluth G, et al. Acad Med. 2014;89:460-8.
This retrospective study found that providing resident and fellow physicians with a financial incentive to meet inpatient quality improvement goals led to enhanced patient safety processes, such as hospital-to-home transitions and timely completion of discharge summaries. These findings highlight a need for broader implementation of trainee incentives as part of quality improvement.