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Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.
Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.
Parshuram CS, Dryden-Palmer K, Farrell C, et al. JAMA. 2018;319:1002-1012.
Identifying incipient clinical deterioration is a prerequisite for rapid response and prevention of harm for hospitalized patients. This study tested a bedside pediatric early warning system, which included an illness severity score, standardized documentation, and monitoring protocols. In a cluster-randomized trial in several high-income countries, implementation of the bundle did not result in decreased in-hospital mortality compared to usual care. The overall mortality rate in the study was less than 0.2%. The authors suggest that this unexpectedly low mortality rate may have made it difficult to detect differences in intervention versus control hospitals. A related editorial suggests that artificial intelligence should be used to identify clinical deterioration and that outcomes beyond mortality should be considered in their evaluation.
Parent B, LaGrone LN, Albirair MT, et al. JAMA Surg. 2018;153:464-470.
Handoffs represent a significant risk to patient safety. Standardizing communication during the handoff process has the potential to reduce harm. In this trial, researchers assessed the impact of a standardized handoff curriculum on perceived interprovider communication in eight intensive care units (ICUs) across two hospital systems. Although the curriculum was perceived to improve shift preparedness among providers, they found no association with better patient outcomes in the ICUs, including length of stay, duration of mechanical ventilation, or reintubations. An accompanying editorial suggests that further research on standardized handoffs in the ICU is necessary to better understand the potential for improving patient outcomes. A previous PSNet interview discussed handoffs and the implementation and findings of the landmark I-PASS study.
Jones PM, Cherry RA, Allen BN, et al. JAMA. 2018;319:143-153.
Handoffs between providers are inevitable and are known to introduce risks. This retrospective population-based cohort study in Canada examined the effects of intraoperative handoffs between anesthesiologists on major complications, readmissions, and 30-day mortality among patients undergoing surgery. After adjustment for patient and site characteristics, patients who experienced an anesthesiologist handoff had higher rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. The number of surgeries in which a handoff occurred increased over time during the 6-year study period. These results suggest that limiting intraoperative anesthesiologist handoffs may improve safety. However, a related editorial posits that reducing handoffs is a simplistic solution that may have unintended consequences and instead recommends that quality improvement approaches, such as developing standardized handoff procedures, may result in more meaningful enhancements for intraoperative anesthesia safety.
Scott AM, Li J, Oyewole-Eletu S, et al. Jt Comm J Qual Patient Saf. 2017;43.
Fragmented care transitions may lead to adverse events due to poor provider communication, disjointed continuation of care, and incomplete patient follow-up. In this study, site visits were conducted at 22 healthcare organization across the United State to determine facilitators and barriers to implementing transitional care services. Identified facilitators included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Results suggest how institutions may wish to prioritize strategies to facility effective care transitions.
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.
Starmer AJ, Sectish TC, Simon DW, et al. JAMA. 2013;310:2262-2270.
Handoff improvement is a national patient safety priority. The Accreditation Council for Graduate Medical Education now requires residency programs to provide formal handoff education to trainees. This study evaluated the implementation of an inpatient handoff bundle for pediatric resident physicians. The multifaceted intervention included team training, standardized communication, electronic documentation, and new team handoff structures. In the uncontrolled, before-and-after analyses, medical errors and preventable adverse events decreased substantially. The intervention did not adversely affect resident workflow. Residents were found to spend more time in direct contact with patients in the post-intervention period. A related editorial notes that this study presents promising evidence that improving handoffs can reduce patient harm.
Callen JL, Westbrook JI, Georgiou A, et al. J Gen Intern Med. 2011;27:1334-1348.
Following up test results in a timely fashion is a recognized patient safety problem in primary care, and inadequate follow-up systems are a source of frustration for outpatient clinicians and a relatively common source of malpractice claims. This systematic review found evidence that failure to act on abnormal radiology or laboratory results is common and clearly linked to missed or delayed diagnoses. The review also found wide variation in processes for handling test results across studies. Electronic health records (EHRs) did appear to improve test follow-up rates, although a substantial proportion of abnormal results were not followed up even with EHRs. The authors advocate for more standardized processes for informing patients of abnormal results, and recent guidelines have been published for organizational policies to improve test result communication.
Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-7.
Care transitions are a vulnerable time for patients, particularly following hospitalization when discharge communication, pending tests, and medication reconciliation are all known challenges. This study analyzed a population-based data set containing both hospitalization and outpatient prescription records to identify the incidence of potentially unintentional medication discontinuation among patients 66 years or older. Analyzing nearly 400,000 patients, investigators found high rates of medication discontinuation ranging from 5% to 19% across 5 evidence-based medication classes (e.g., lipid lowering, thyroid replacement, antiplatelet agents) for hospitalized patients. Admission to the ICU was associated with an even greater risk of medication discontinuation. While some medication discontinuation is not surprising in the setting of a critical illness that may create new contraindications to preexisting medications, both this study and an accompanying editorial [see link below] raise appropriate concern about carefully reconciling chronic disease medications following hospitalization. A past AHRQ WebM&M conversation and perspective discussed the challenges and opportunities for improving care transitions.
Voss R, Gardner R, Baier R, et al. Arch Intern Med. 2011;171:1232-7.
The Partnership for Patients has set a goal of reducing preventable hospital readmissions 20% by the year 2013. This goal was achieved by the landmark care transitions study. However, since that study was conducted in an integrated health care system, concerns linger about the generalizability of the intervention to other settings. This study, funded by the Centers for Medicare and Medicaid Services, sought to evaluate the real world effectiveness of the care transitions intervention at six hospitals in a non-integrated health care system. Despite logistical challenges, the intervention successfully reduced readmissions by 36% in patients who received it compared with patients who did not receive any component of the intervention. As hospitals continue to investigate ways of preventing readmissions and reducing adverse events after discharge, this study provides reinforcement for comprehensive interventions that attempt to bridge the gap between inpatient and outpatient care.
Callen J, Georgiou A, Li J, et al. BMJ Qual Saf. 2011;20:194-199.
Adverse events after hospital discharge are a growing driver for safety interventions, including a focus on readmissions, adverse drug events, and hospital-acquired infections. Another safety area ripe for intervention is managing test results after hospital discharge. This systematic review analyzed 12 studies and found wide variation in rates of test follow-up and related management systems. Critical test results and results for patients moving across health care settings were highlighted as particularly concerning areas that could be addressed with better clinical information systems. A past AHRQ WebM&M commentary discussed a case where a patient was incorrectly treated based on failure to follow up a urine culture after hospital discharge.
Catchpole K, Sellers R, Goldman A, et al. Qual Saf Health Care. 2010;19:318-22.
Transfer of patients from the operating room to intensive care involves exchange of complex information between multiple providers in a short period of time.  In an innovative effort to apply principles from other industries to medicine, this study used interviews with the managers of Formula One auto racing teams to determine the key elements of racing "pit stops" and draw lessons for improving the safety of the postoperative handover process. The key lessons learned from the auto racing approach—proactive planning, active management of the handover process using information technology, and post hoc learning by data monitoring and analysis—have subsequently been applied to standardize and improve the postoperative handover process.
Rivera-Rodriguez AJ, Karsh B-T. Qual Saf Health Care. 2010;19:304-312.
The majority of individual errors are due to failure to perform automatic or reflexive actions. A major risk factor for these "slips" is being interrupted or distracted while performing a task. This review examined the literature on the incidence, risk factors, and effects of interruptions in several clinical settings, ranging from outpatient clinics to the operating room. Although distractions are common and may be associated with increased risk for error, particularly if they occur during medication administration or signout, the authors point out that many interruptions may be necessary to communicate urgent clinical information. They argue for complexity theory–based research to delineate the harmful and beneficial aspects of interruptions, rather than for interventions that seek to simply eliminate interruptions. Checklists have been widely adopted as a means of preventing errors of omission, which may be precipitated by interruptions.
Singh H, Thomas EJ, Mani S, et al. Arch Intern Med. 2009;169:1578-1586.
Inadequate follow-up of diagnostic testing is a known safety issue in both hospital and ambulatory settings. Adoption of information technology approaches serves as a logical solution if designed to effectively notify providers of pending or necessary follow-up actions. This study used tracking software to determine if an electronic alert for abnormal imaging results was acknowledged and acted upon in a Veterans Affairs ambulatory setting. Investigators discovered that their seemingly fail-proof system, which included dual-alert communications, still led to persistent problems with missed test results. They also found that the dual-alert communication system was unexpectedly associated with a lack of timely follow-up. The authors advocate for greater multidisciplinary approaches to address these breakdowns.
Were MC, Li X, Kesterson J, et al. J Gen Intern Med. 2009;24:1002-6.
Adverse events after hospital discharge are a continued threat to patient safety and a significant source of communication failures, particularly for tests that are pending at discharge. This study reviewed nearly 700 discharge summaries from two academic centers and found that only 16% of pending tests were mentioned and that only 13% of discharge summaries listed all pending tests. Equally concerning was that follow-up providers' information was documented in only 67% of cases. Recognition of these problems has led to the development of discharge checklists and reengineering of the process. A past AHRQ WebM&M perspective and interview discussed issues around safe care transitions.
Schnipper JL, Hamann C, Ndumele CD, et al. Arch Intern Med. 2009;169:771-80.
Attempts to reduce medication discrepancies in hospitalized patients have been hampered by a lack of proven medication reconciliation strategies. In this cluster-randomized trial, a previously described electronic medication list that required input from nurses, physicians, and pharmacists was implemented at two academic hospitals. The tool resulted in a significant reduction in potential adverse drug events at discharge. However, potential drug errors still occurred at a rate of one per patient even after implementation. The intervention was more successful at preventing medication discrepancies among high-risk patients. This study is one of the first randomized trials of a medication reconciliation intervention, and points the way toward identifying medication reconciliation tools that are widely applicable.
van Walraven C, Taljaard M, Bell CM, et al. CMAJ. 2008;179:1013-8.
Significant attention to gaps in the continuity of care has led to past research focused on hospital transitions and medication management systems in the ambulatory setting. This study tracked information exchange between outpatient providers caring for the same patient following hospital discharge. Remarkably, they discovered that information from the previous visit was available at a subsequent visit only 22% of the time. Factors associated with information being available included care by a family physician and whether that physician was treating the patient prior to hospitalization. The findings raise ongoing concerns about poor communication and highlight the need for systems to foster more effective clinical information exchange between providers. A past AHRQ WebM&M perspective discussed care transitions associated with hospital discharge.
Roy CL, Kachalia A, Woolf S, et al. J Gen Intern Med. 2009;24:374-80.
Hospital readmissions are garnering increased attention as a potential measure of care transition quality. When readmissions occur, providing feedback to the team that originally discharged the patient could be valuable. This study, conducted at two academic medical centers, found that discharging physicians frequently were not informed that their patient had been readmitted. Communication between discharging and readmitting teams took place in a minority of cases, even though most clinicians felt that communication would have been useful. A recent AHRQ WebM&M perspective discussed hospital readmissions as well as methods to reduce them, including use of a transitions coach.
Loren DJ, Klein EJ, Garbutt J, et al. Arch Pediatr Adolesc Med. 2008;162:922-927.
Studies of medical error disclosure have demonstrated that, while physicians support disclosure of errors in theory, most "choose their words carefully" in practice and fail to disclose important elements of the error. In this study, pediatricians were presented with error scenarios and asked to describe what they would disclose to the child's parents. Overall, a minority of physicians would fully disclose the error, and most would not offer an explicit apology. An accompanying editorial discusses barriers to disclosing errors and strategies (including communication training) that should be implemented to improve this aspect of patient–physician communication.
Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-85.
Direct observation of teamwork during surgical procedures revealed that poor teamwork was associated with higher rates of postoperative complications and overall mortality, even after adjusting for preoperative risk. Though suboptimal teamwork is a recognized problem in the operating room, this study is one of the first to directly link team behavior to patient outcomes. One method of improving teamwork, crew resource management training, has been extensively evaluated in a variety of clinical settings. A near miss resulting from poor teamwork is illustrated in a recent AHRQ WebM&M commentary.