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.
Starmer AJ, Michael MM, Spector ND, et al. Jt Comm J Qual Patient Saf. 2023;49:384-393.
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.
Paydar-Darian N, Stack AM, Volpe D, et al. Pediatrics. 2022;150:e2021054307.
Errors during the discharge process can lead to return visits and adverse health outcomes. This article describes the implementation of a new standardized discharge process (including a new checklist, provider huddle, and scripted caregiver education) at one children’s hospital. Over a 19-month period, implementation of the revised discharge process led to the elimination of preventable, discharge-related serious safety events and did not result in increased length-of-stay or return visits.
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
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.
Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Pediatr Qual Saf. 2022;7:e539.
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.
Huth K, Stack AM, Hatoun J, et al. BMJ Qual Saf. 2021;30:208-215.
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.
Brunsberg KA, Landrigan CP, Garcia BM, et al. Acad Med. 2019;94:1150-1156.
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.
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.
Huth K, Stack AM, Chi G, et al. Jt Comm J Qual Patient Saf. 2018;44:719-730.
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.
Sundberg M, Perron CO, Kimia A, et al. Diagnosis (Berl). 2018;5:63-69.
In the Improving Diagnosis report, the National Academy of Medicine called for broad-scale efforts to reduce diagnostic errors. This retrospective cohort study employed natural language processing to identify dangerous diagnoses that pediatric emergency medicine physicians missed. A past WebM&M commentary laid out challenges in classifying diagnostic errors.
… embrace best practices in signout. … The Commentary … by AmyJ. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH … … risk thereof" ( 1 )—reported to The Joint Commission (G. R. Castro, written communication) in 2016 involved handoff …
Starmer AJ, Schnock KO, Lyons A, et al. BMJ Qual Saf. 2017;26:949-957.
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.
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.
Standardized handoff protocols have been shown to reduce adverse events among hospitalized patients. This study reports on the development and validation of a tool for assessing the quality of verbal handoffs between pediatric residents. The tool demonstrated excellent potential for evaluating resident handoff skills, but the authors note that observation of more than 20 handoffs per resident would be required to determine competency.
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.
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.