Handoff bundle reduces errors, improves workflow

Implementing a resident handoff bundle decreased error rates and improved care processes and workflow, researchers reported in the Dec. 4 issue of JAMA. Using a computerized handoff also cut down on omission of key data.

Amy J. Starmer, MD, MPH, of Boston Children’s Hospital, and colleagues used a pre-post design to assess a resident handoff bundle intervention in two units. Before the intervention, interns and residents performed verbal handoffs independently and had no standardized structure or quiet place for handoffs. They used a printed handoff that was not integrated into an EMR.

In October 2009, the hospital implemented an intervention that included a training session, a mnemonic device to standardize verbal handoffs, a unified intern-resident team handoff, use of quiet or private spaces and periodic handoff oversight. One unit incorporated a computerized handoff tool that automatically imported patient data into an EMR.

Starmer et al collected data from July through September 2009 using observational and survey techniques and compared it with data from November 2009 through January 2010. They focused on medical error rates, miscommunications and workflow. The researchers enrolled 84 residents (42 pre- and 42 post-intervention) and reviewed 1,255 patient admissions (642 pre- and 613 post-intervention).

They found that overall medical error rates dropped from 33.8 to 18.3 per admissions. Preventable adverse event rates were halved, from 3.3 to 1.5 per 100 admissions. Both units showed improvements in omission of key data, but the unit with the computerized handoff tool achieved greater improvement, with a significant reduction in 11 categories compared with two categories for the other unit.

Post-intervention, residents spent more time with patients and their families and posted the same amount of time at the computer or editing computerized handoff forms. The amount of time devoted to writing on printed handoff copies dropped by half.

Residents spent the same amount of time on verbal handoffs but were more likely to hold the sessions in a quiet or private location.

“To maximize the chance that the handoff intervention would lead to measurable improvements in care, we chose to bundle together several evidence-based interventions. … A limitation of this approach, however, is that it prevents us from directly associating most observed changes with particular elements of the bundle so that it remains unclear which elements of the bundle are most important or whether all elements are needed together,” they wrote.

Starmer et al acknowledged that other factors may have played a role in the improvements, including differences in patient populations, residents’ experience and ongoing patient safety programs. The automatic importing of data in the one unit was a technical rather than a behavioral change, too.  

“Regardless of how the change was accomplished, however, we believe the inclusion of more complete handoff data [is] valuable,” they wrote.