Rates per 100 Admissions Pre-RHB Post-RHB p-value Medical Errors 33.8 18.3 6,000 caregivers Multiple types and lengths of training Open forums, grand rounds, departmental meetings New resident orientation Varied educational content-lecture, videos, simulations Adapt I-PASS to caregiver and venue needs, workflows Norman Knight Center trained 4000 nurses Necessarily asynchronous rollout over several years Always start with rationale and evidence base for I-PASS Start with shift to shift handovers JAMA 2013 310:Ĥ Results: Medical Error and Preventable Adverse Events Resident Handoff Bundle (RHB) + + = Communication and handoff skills training Redesigned Verbal Handoff Process Mnemonic + Computerized Handoff Tool (Unit 1 only) Starmer AJ, Sectish TC, Simon DW, Keohane C, McSweeney ME, Chung EY, Yoon CS, Lipsitz SR, Wassner AJ, Harper MB, Landrigan CP. Sentinel Event Statistics Data - Root Causes by Event Type ( Third Quarter 2011)ģ Handoff Bundle Intervention: Boston Children’s Hospital Sentinel event statistics data: root causes by event type. This presentation contains copyrighted materials with permission from Boston Children’s Hospital and the I-PASS Study Group.Ĭommunication failures, including failures in handoff communication, are the major root cause of sentinel events reported to the JCAHO Reference The Joint Commission. Landrigan, MD, MPH Massachusetts Coalition for the Prevention of Medical Errors MaPermissions: The IIPE logo is used with permission from the Initiative for Innovation in Pediatric Education The PRIS logo is used with permission from the Pediatric Research in Inpatient Settings Network Some content in the I-PASS Handoff Study Curriculum includes materials adapted from TeamSTEPPSTM, an evidence-based teamwork curriculum developed by the Agency for Healthcare Research and Quality. 2010 24:140.Presentation on theme: "I-PASS: Improving, Disseminating, and Sustaining Safer Handoffs"- Presentation transcript:ġ I-PASS: Improving, Disseminating, and Sustaining Safer HandoffsĬhristopher P. Emergency physician intershift handover – can a dINAMO checklist speed it up and improve quality? Swiss Med Wkly. Rüdiger-Stürchler M, Keller DI, Bingisser R. Association of American Medical Colleges Web site. Published August 2010.Ĭore Entrustable Professional Activities for Entering Residency: Faculty and Learners’ Guide. Accreditation Council for Graduate Medical Education Website. Changes in Medical Errors after Implementation of a Handoff Program. Starmer AJ, Spector ND, Srivastava R, et al. Joint Commission Center for Transforming Healthcare Web site. Improving Transitions in Care: Handoff Communications. Implementation and outcome research is needed to investigate if the I-PASS tool is feasible and improves patient outcomes in the ED environment. This study provides qualitative data in support of using the I-PASS tool and concrete suggestions for how to modify the I-PASS tool for the ED. With modifications for context, brevity, and clarity, the I-PASS system may be well suited for application to the ED setting. Most participants agreed that the I-PASS tool would be well suited to the ED setting. Themes from all qualitative sources converged to suggest changes for brevity and clarity. The survey yielded several wording changes to reflect contextual differences. Participants generally endorsed the order and content of the other elements of the I-PASS tool. We sought to identify the distinctive elements of ED handoffs and discern how these could be incorporated into the I-PASS system.įocus group participants agreed the patient summary should be adapted to include anticipated disposition of patient. We conducted a literature review, focus groups, and then a survey. This mixed-method needs assessment conducted at an academic ED explored the suitability of the I-PASS system for ED handoffs. We aimed to explore what modifications the I-PASS (illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver) handoff system requires to be effectively modified for use in ED inter-shift handoffs. Emergency medicine residents are inadequately trained to handle these vital transitions. Academic emergency department (ED) handoffs are high-risk transfer of care events.
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