• DOI:10.1056/NEJMsa1405556
• Corpus ID: 22174350

Changes in medical errors after implementation of a handoff program.

@article{Starmer2014ChangesIM,
  title={Changes in medical errors after implementation of a handoff program.},
  author={Amy Jost Starmer and Nancy D. Spector and Rajendu Srivastava and Daniel C West and Glenn Rosenbluth and April D Allen and Elizabeth L Noble and Lisa L Tse and Anuj K. Dalal and Carol A. Keohane and Stuart R. Lipsitz and Jeffrey M. Rothschild and Matthew Wien and Catherine S. Yoon and Katherine Zigmont and Karen M. Wilson and Jennifer K. O’Toole and Lauren G. Solan and Megan Aylor and Zia Bismilla and Maitreya Coffey and Sanjay Mahant and Rebecca Blankenburg and Lauren A. Destino and Jennifer L. Everhart and Shilpa J. Patel and James F. Bale and Jaime B Spackman and Adam T Stevenson and Sharon Calaman and F. Sessions Cole and Dorene F Balmer and Jennifer H Hepps and Joseph Lopreiato and Clifton E. Yu and Theodore C. Sectish and Christopher P. Landrigan},
  journal={The New England journal of medicine},
  year={2014},
  volume={371 19},
  pages={
          1803-12
        }
}

• A. Starmer, N. Spector, +34 authors C. Landrigan
• Published 5 November 2014
• Medicine
• The New England journal of medicine

BACKGROUND
Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking.

METHODS
We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events.

RESULTS
In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time.

CONCLUSIONS
Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).