Standardized patient handoffs can reduce care failures by 69 percent, study finds

Carrie Christian (left) and Katy Saiben discuss the medical care of a patient during the handoff as Christian's shift ends and Sabien's begins. (Ed Suba Jr./Akron Beacon Journal)

Carrie Christian (left) and Katy Saiben discuss the medical care of a patient during the handoff as Christian’s shift ends and Sabien’s begins. (Ed Suba Jr./Akron Beacon Journal)

When children become critically ill, there’s a constant transfer of information and responsibility between providers while they’re in the hospital.

These incidents are called patient handoffs, and, if not done in a standardized way, can lead to failures in care, such as a missed medication or delayed treatment, according to a recent study published in the July issue of Pediatrics.

In the yearlong study, “Decreasing Handoff-Related Care Failures in Children’s Hospitals,” 23 children’s hospitals across the country examined 7,864 patient handoffs and the effect of implementing standardized procedures to reduce miscommunication and care failures during the handoff process. The study did not directly measure patient harm, but rather a predicate marker of harm.

Dr. Michael Bigham

Dr. Michael Bigham

“Every day the children being cared for at Akron Children’s Hospital experience thousands of (patient) handoffs,” said pediatric critical care doctor Michael Bigham and lead author of the study. “Sometimes those handoffs are from employees who are changing shifts and the patient stays in the same place, and sometimes it’s the patient who’s changing locations within the hospital. There is a risk to patient safety when patient handoff occurs.”

As a result, the hospitals decreased handoff-related failures by 69 percent during the course of the study.

Keys to smoother handoffs

As part of the study, Akron Children’s examined 3 different types of handoffs and saw a 36 percent reduction in handoff-related failures.

The handoff scenarios included:

  • The transition of patient care responsibility during shift change for nurses (e.g., night shift to day shift and vice versa)
  • The patient’s transition from the ER to inpatient
  • The temporary transition of an inpatient to and from radiology

Dr. Bigham, who has been looking at ways to improve handoffs for the past 6 years, said the 3 keys to smoother patient handoffs are:

  • implementing a standard procedure for handoffs
  • eliminating distractions during the handoff process
  • clear transition of responsibility from caregiver to caregiver

“We are excited to be part of this larger project to target improvements nationally,” Dr. Bigham said. “We recognize the safety risk for our patients and that we need to do something. We wanted to take what we were doing in the smaller setting to help make a bigger impact in a collaborative setting. This collaborative study gave us an opportunity to learn from others and also to teach others.”

Focus on improving patient handoffs

Patient handoffs have been identified as a major patient safety concern by major healthcare organizations, including The Joint Commission, the World Health Organization and the Institute of Medicine.

In 2006, The Joint Commission required accredited hospitals to implement a standardized handoff process, and in 2007, the WHO highlighted the role standardized processes had in reducing handoff-related errors. In 2008, the IOM recommended focusing on handoff processes to improve patient safety.

Read more in media coverage

Children’s Hospital tackles potential errors by improving patient handoffs, Akron Beacon Journal

Improving the “handoff” in children’s hospitals cuts down on errors, Akron Children’s study shows, Cleveland Plain Dealer


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