Better handoffs improve safety at children’s hospitals

Pediatric patients might be at particular risk

Eliminating distractions and standardizing the process for patient handoffs has helped a group of children’s hospitals reduce handoff errors by 69%.

Patient handoffs are increasingly recognized as potential threats to patient safety, and critically ill children might be even more at risk than other patients, says pediatric critical care doctor Michael Bigham, MD, at Akron (OH) Children’s Hospital. Responsibility for critically ill children is frequently transferred from one clinician or unit to another, he notes. Because of their ages, pediatric patients might be affected more by errors that occur with the handoff.

Bigham has studied how to improve patient handoffs for six years. He led the team that recently published a yearlong study, "Decreasing handoff-related care failures in children’s hospitals," which involved 23 children’s hospitals across the country. The researchers examined 7,864 patient handoffs and the effect of implementing standardized procedures to reduce miscommunication and care failures during the handoff process. The study did not directly measure patient harm, but rather a predicate marker of harm. (See the story on page 175 for more on the study.)

A major safety concern

Patient handoffs have been identified as a major patient safety concern by major healthcare organizations, including The Joint Commission (TJC), the World Health Organization (WHO), and the Institute of Medicine (IOM). In 2006, The Joint Commission required accredited hospitals to implement a standardized handoff process, and in 2007, the WHO highlighted the role standardized processes had in reducing handoff-related errors. In 2008, the IOM recommended focusing on handoff processes to improve patient safety.

"The Joint Commission has looked at a decades’ worth of sentinel events between 1995 and 2005, and breakdown in communication was the leading root cause of sentinel events in that period of time," Bigham says. "The IOM also has stated that inadequate handoffs are where the safety process fails first. Handoff failures are a huge risk to patient safety."

With years of emphasis on improving patient handoffs, Bigham and his colleagues realized that among children’s hospitals, handoffs were the poorest performing safety domain. Early in the study research, Bigham and others investigated the baseline rate of handoff failure at the hospitals. Selecting patient handoffs at random, they interviewed the receiving patient care team about whether they had encountered any care failures as a result of inaccurate or missing information at the handoff.

Patient safety leaders from the hospitals studied their data on patient handoffs and also developed a "change package" that explains the components necessary to improve the process. The researchers developed these four key steps:

• Define the handoff intent.
• Define the handoff content.
• Define the handoff process.
• Combine all of those in a way that maximizes teamwork.

The hospital leaders recognized early on that there would be no single way to roadmap the handoff procedure that would work for every hospital. Instead, each hospital identified the pertinent handoff scenarios in their facilities, applied those steps to their own facilities, and developed their own improvements. As a result of process improvements flowing from the research, the participating hospitals decreased handoff-related failures by 69% during the study.

"The solutions developed at the different hospitals were shared with the other participants, so people could pick and choose the parts they liked and apply them to their own settings," Bigham says. "At the end of a one-year cycle, all 23 hospitals had either moderate-scale or large-scale implementation of improvements involving one or more different types of handoffs."

When the research team compared the handoff failure rates at the end of the study, they found that the hospitals had reduced the rate of failures by 69%.

"We were confident that by the end of this process, our patients were safer and subject to far fewer patient care problems from miscommunication at handoffs," Bigham says.

Though the improvement plans were specific to each hospital, all of them followed the four key steps.

Reducing distractions

Akron Children’s examined three types of handoffs and saw a 36% reduction in handoff-related failures. The handoff scenarios included:

• The transition of patient care responsibility during shift change for nurses, such as night shift to day shift and vice versa.
• The patient’s transition from the emergency department to inpatient.
• The temporary transition of an inpatient to and from radiology.

Akron Children’s implemented a standard procedure for handoffs designed to eliminate distractions during the handoff process and result in a clear transition of responsibility from caregiver to caregiver, explains Quality Director Cathy Gustaevel, who also is responsible for patient safety. Many of the changes encourage face-to-face interactions, rather than leaving notes for other caregivers, Gustaevel explains.

"I think the impact is going to be huge. The improved process is going to give us some consistency and reliability that what happens in the emergency room as far as handoffs is the same as what happens in critical care," Gustaevel says. "This will increase the safety of the kids because standardization often reduces or eliminates errors. Everyone here knows that the person on the other side of the handoff will do it the same way you’ve been trained, and they will do it that way every single time."

Some clinicians resisted the handoff improvements at first but warmed to the idea as they saw how the standardized procedure reduced errors, Gustaevel says. Children’s Hospital also involves parents in the handoff procedure, with the theory being that they know everything about their child far better than anyone else. The parents listen in and are encouraged to add their own comments or to question the handoff information.

But are the practices developed in the course of the children’s hospital study any different from what hospitals already have been trying?

"I’m not sure hospitals have really been trying to improve handoffs. Either hospitals have not improved their processes or what they tried is not working," Bigham says. "This concept of patient handoffs cannot be ignored any longer. Patient handoffs should be just as important to patient safety as the surgical procedure itself and the right settings on the ventilator."