Miscommunication between caregivers is one of the largest causes of medical errors, but a new study published this week in the New England Journal of Medicine suggests that the problem is at least partly preventable.
The study at nine children's hospitals, led by Boston Children's Hospital and including our own Lucile Packard Children's Hospital Stanford, tested the effects of a standardized method for medical residents to hand off information about their patients at shift changes. Shorter shifts for residents have increased the number of such hand-offs, putting the hand-offs themselves under more scrutiny in recent years.
At each participating hospital, medical residents were trained to use an acronym that reminded them what information to share about each patient, and in what order. The hand-off process included both oral and written communication, and ended with the person who was receiving the information repeating back a summary of what was shared with the person who gave it. The program also included other supports to ensure that the hand-off procedure was embedded in the hospital's culture and did not have a negative effect on the doctors' overall workflow.
The participating hospitals reduced their rate of medical errors by 23 percent, and preventable adverse events dropped by 30 percent. From a Boston Children's press release about the research:
"Because we know that miscommunications so commonly lead to serious medical errors, and because the frequency of handoffs in the hospital is increasing, there is no question that high-quality handoff improvement programs need to be a top priority for hospitals," says [lead study author Amy] Starmer. "It's tremendously exciting to finally have a comprehensive and rigorously tested training program that has been proven to be associated with safer care and that meets this need for our patients."
The program tested in the new research is available for free to any hospital that wants to implement it.
Previously: New study shows standardization makes hospital hand-offs safer, Less burnout, better safety culture in hospitals with hands-on executives, new study shows and Automated safety checklists prevent hospital-acquired infections, Stanford team finds