The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.

Multiple handoffs during perioperative care present opportunities for error. This article outlines a conceptual framework to support the development, implementation, and evaluation of patient-centered handoffs during perioperative care. The authors describe a multi-component handoff improvement bundle including mnemonics and checklists (such as I-PASS), technology solutions to reinforce verbal handoffs, interprofessional handoff training and assessment, and leadership support to promote safety culture.

I-PASS, a structured hand-off tool, can reduce preventable adverse events during transitions of care. Previously published studies have shown that Patient and Family-Centered (PFC) I-PASS rounds reduced preventable and non-preventable adverse events (AE) in hospitalized children. This study presents additional analysis, comparing AE rates in children with complex chronic conditions (CCC) to those without. Results show a reduction in AE in both groups, with no statistically significant differences between the groups, suggesting PFC I-PASS may be generalizable to broader groups of patients without needing modification.

Learning from mistakes is an essential component of medical and nursing education. This retrospective study examined medical errors and near-misses committed by nursing students at more than 200 prelicensure programs. Of the 1,042 errors and near-misses reported, medication errors were most common (59%). Three primary contributing factors to errors and near-miss events were identified – (1) not checking patient identification, (2) not checking a patient’s allergy status, and (3) not following the “rights” of medication administration.

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.

… length-of-stay or return visits. … Paydar-Darian N, Stack AM, Volpe D, et al. Improving discharge safety in a pediatric emergency …

Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.

I-PASS is a structured handoff tool designed to improve communication between teams at change-of-shift or between care settings. This children’s hospital implemented an I-PASS program to improve communication between attending physicians and safety culture. One year after the program was introduced, all observed handoffs included all five elements of I-PASS and the duration of handoff did not change. Additionally, the “handoff and transition score” on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture improved.

… this vulnerable group of children. … Khan A, Yin HS, Brach C, et al. Association between parent comfort with English and …

Over a three-year period, this study audio-recorded handoffs of outpatient clinics to a pediatric emergency department (ED) to determine whether use of a receiver-driven structured handoff intervention can reduce miscommunication and increase perceived quality, safety, and efficacy. Implementation of the tool resulted in a 23% relative reduction in miscommunication and in increased compliance with handoff elements, including illness severity, pending tests, contingency plans, and detailed callback requests, as well as improved perceptions of healthcare quality, safety, and efficiency.

Physician burnout and depression are prevalent, costly, and likely to worsen the existing physician shortage. Physicians with depression and burnout also report committing more errors than their peers. Investigators prospectively examined whether pediatric residents reporting depression or burnout were involved in more errors. Participants experiencing depression committed three times as many harmful errors as those without depression. Residents with burnout did not commit more errors or more harmful errors. A strength of this study is that the errors were assessed objectively rather than by self-report. The direction of causality remains unclear—whether physicians with depression commit more harm or committing harm leads to depression. A past PSNet interview discussed how to promote physician satisfaction and well-being.

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.

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.

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.

Successful initiatives that have enhanced the safety of handoffs have largely focused on the inpatient setting. This study determined that handoffs between outpatient pediatric providers and the emergency department at a single institution varied in quality, which can lead to unnecessary testing and other harm. A past Annual Perspective discussed how robust handoffs may improve safety outcomes.

… safety campaigns at academic centers. Two WebM&M commentaries explore the risks of handoffs and how to …

… emergency medicine physicians missed. A past WebM&M commentary laid out challenges in classifying diagnostic …

This pre–post study aimed to increase error reporting by pediatric resident physicians and medical students. Residents and medical students reported more errors after implementation of a monthly educational conference in which event reports were reviewed. The authors conclude that trainee-led adverse event review conferences can increase event reporting.

Handoffs increase the risk of adverse events, mainly due to lapses in communication. Implementation of a standardized approach to handoffs may help improve patient safety. This prospective pre–post intervention study examined the impact of a multicomponent handoff intervention consisting of education, verbal handoff mnemonic implementation (I-PASS), and visual aids on nursing handoffs. Researchers used assessment tools to evaluate both the quality and duration of handoffs. Implementation of the intervention was associated with an overall improvement in the handoff process and did not adversely impact nursing workflow. A previous Annual Perspective highlighted safety issues related to handoffs and care transitions.