Overview

This project at an academic medical center implemented a web-based handoff tool and training for health care personnel to reduce medical errors in the care of medical and surgical patients. 

Organization Name

Brigham and Women’s Hospital

Organization Type

• Academic Medical Center
• Integrated healthcare system/network

National/Policy Context

• In academic medical centers, patient handoffs between health care personnel have been increasing in frequency, in particular in the period following implementation of restricted resident work hours (Mueller et al., 2016).
• Errors in communication often happen during patient handoffs. 

Patient Population Served and Payor Information

• Brigham and Women’s Hospital accepts Medicare/Medicaid and private insurance. Most patients reside in Massachusetts and the surrounding states.

Leadership

• The authors — Stephanie K. Mueller, MD, MPH, Catherine Yoon, MS, and Jeffrey L. Schnipper, MD, MPH — spearheaded the project and provided leadership on an ongoing basis.  

Funding

• Funding for the project came from the Department of Medicine at Brigham and Women’s Hospital. 

Research + Planning

• Before implementation of the project, auto-population of patient information was performed using the existing EMR and existing workflows were merged so users could update the handoff and progress notes at the same time
• Templated fields were created to direct users on what clinical information to include so that the implementation would be more straightforward for those involved. 
• These steps streamlined the implementation process.
• The planning team also consulted these two resources during research and planning:
  • National Coordinating Council for Medication Error Reporting and Prevention Scale: This scale classifies errors according to severity of outcome.
  • TeamStepps: This project trains health care professionals to use a set of teamwork tools to improve communication and teamwork skills.

Training

• Health care professionals (all medical and surgical residents, medical hospitalist attendings, surgical chief residents) were trained to use the web-based hand-off tool that uses the IPASS mnemonic to provide a guideline for the patient handoff process. The IPASS mnemonic stands for “illness severity, patient summary, action list, situation awareness and contingency planning, and synthesis by receiver.”
• They were also trained to use TeamSTEPPS, a set of teamwork tools, to hone their teamwork and communication skills.
  • Health care professionals were also given additional clinical champion training on proper use of the tool. 
• This training took 3 months. 

Tech Involved

• Electronic medical record

Team Members Involved

• Physicians

Workflow Steps

• Residents and attending physicians used the handoff tool during their shifts. The tools streamlined their workflow with features such as auto-populating key fields from the EHR, templated fields with prompts letting the physician know what information to include, and training information on using TeamSTEPPS in their communication.
• Validated surveillance surveys were given to resident physicians at the end of their “nightfloat” (12am to 7am) and “twilight” (4pm to 12am) shifts. They were also given to resident physicians and attending physicians 2 days after they started their general medical or surgical service. The surveys asked about satisfaction, efficiency, and errors in communicating information such as resuscitation preferences and medication orders.
• The ratings (presence of errors, level of harm, attribution to failures in communication and handoff, preventability of harm with incidents) were judged by a physician who was blinded to the studied intervention timeline. 
• Any discrepancies in ratings resulted in a review of the medical record, and then the final determination of the rating was done by the adjudicator (Stephanie K. Mueller, one of the authors).

Budget Details

The following sources of costs were estimated by the CareZooming team:

• Cost of developing web-based handoff tool
• Labor costs associated with additional training for all staff members involved

Where We Are

• Date (Month/Year) Project Described Started: Nov 1, 2012
• Date (Month/Year) Paper Published: Feb 1, 2014

Outcomes

• Rate of medical errors: There was a significant reduction in medical errors post-implementation compared to pre-implementation, particularly in those errors resulting from communication failures (rate of 3.56 per 100 patient-days for period 1 compared to rate of 1.76 per 100 patient-days for periods 2 and 3). 
• Rate of medical errors following concurrent care team regionalization: There was a synergistic effect on the rate of medical errors following regionalization of general medical services to one nursing unit; after the merging of all general medical services to one nursing unit, medical errors decreased even more.   

Benefits

• The major benefit of this intervention was the decreased amount of medical errors as a result of reduction in communication failures.
• Synergistic benefits materialized from concurrent care team regionalization because of even greater improvements to communication with the localization of medical services to one nursing unit. 

Unique Challenges

• There may have been difficulties persuading resident and attending physicians fill out surveys after their long work-shifts.

Sources

• This primer was developed by the CareZooming team based on our analysis of a research article found and accessed through public sources. Authors were able to review the contents of this primer before publication, and all requested edits have been incorporated into the primer as presented above.
• Mueller, S.K., Yoon C., Schnipper J.L. (2016). Association of a Web-Based Handoff Tool With Rates of Medical Errors. JAMA Intern Med, 176(9), 1400-2.
• Accreditation Council for Graduate Medical Education. Duty hours. http://www.acgme.org/What-We-Do/Accreditation/Duty-Hours. Accessed May 10, 2016.