Handoff Communication Bundle Reduces Adverse Events among Hospitalized Children

December 11, 2013 | Strategic Insights for Health System


Implementation of a handoff communication bundle for resident physicians reduced the rate of medical errors among hospitalized children from 33.8 per 100 admissions to 18.3 per 100 admissions, according to the results of a study published in the December 4, 2013, issue of the Journal of the American Medical Association. The study, which prospectively analyzed 1,255 patient admissions involving 84 resident physicians on two inpatient units at a Massachusetts children’s hospital, found that implementation of the bundle also reduced the rate of adverse events from 3.3 per 100 admissions to 1.5 per 100 admissions. The bundle was an educational and systems-based handoff intervention that consisted of three components: (1) a 2-hour communication training session that introduced elements of TeamSTEPPS, which included interactive discussion regarding best practices for verbal and written handoffs; (2) introduction of the SIGNOUT? mnemonic to standardize verbal handoffs; and (3) the restructuring of verbal handoffs to include integration of interns’ and senior residents’ separate handoffs into a unified team handoff, relocation of handoffs to a private and quiet space, and introduction of periodic handoff oversight by a chief resident or attending physician. The data indicated that, postintervention, physicians spent a greater percentage of time in a 24-hour period at the patient bedside than preintervention (10.6% versus 8.3%).

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