Improving Handoffs to Reduce Medical Errors

handoff  In a before/after study involving 84 pediatric residents at a US teaching hospital, implementation of a multifaceted handoff program was associated with a significant reduction in medical errors and preventable adverse events among hospitalized children.  The handoff bundle consisted of a 2-hour communication training session, standardized verbal handoffs, and implementation of a team handoff, as well as a computerized handoff tool linked to the electronic medical record for 1 unit in the hospital. Medical errors decreased from 33.8 to 18.3 per 100 admissions. Although limited by an uncontrolled study design and somewhat surprising to find such a large effect size, focusing on improving handoffs makes sense, and may in fact improve patient outcomes.—Sarang Kim, MD

Starmer AJ, Sectish TC, Simon DW, Keohane C, McSweeney ME, Chung EY, Yoon CS, Lipsitz SR, Wassner AJ, Harper MB, Landrigan CP. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA 2013;310:2262

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