Blazin LJ, Sitthi-Amorn J, Hoffman JM, et al. Pediatr Qual Saf. 2020;5:e323.
This article describes one pediatric hospital’s experience adapting and implementing the I-PASS handoff program for inpatient nursing bedside report, physician handoff, and imaging/procedures handoff. The project demonstrates that I-PASS can be successfully used across a hospital system in various settings to reduce handoff-related errors.
Bittle MJ, Charache P, Wassilchalk DM. Jt Comm J Qual Patient Saf. 2007;33:25-33.
In response to multiple incidents of registration-associated patient misidentification (eg, assigning a new patient an existing patient's medical record number), an interdisciplinary team used plan-do-study-act methodology to investigate the root cause of such errors and formulate solutions. Several system problems were identified, ranging from inadequate training of registrars to the lack of a true master list of patients' medical record numbers. The authors describe the iterative process used to identify and address sources of error at several points within the patient registration process.
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