Roughly 80% of serious medical errors (now the third leading cause of death in the United States behind heart disease and cancer) can be traced to poor communication between care providers during patient handoffs, according to a 2012 Joint Commission report. This makes patient handoffs the most frequent and riskiest procedure in the hospital.
How One Hospital Improved Patient Handoffs for the Long Term
A six-step process helped them engage staff and sustain change.
April 30, 2018
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Summary.
Despite the development of numerous techniques and tools to improve patient handoffs, we haven’t seen much improvement in reducing medical errors that result from them. The problem is two-fold: first, hospital administrators and managers struggle to effectively implement these tools. Second, they struggle to sustain change that’s made. The perioperative unit at Midland Memorial Hospital (MMH) in Texas was in precisely that situation. Leaders noticed that the majority of patient handoffs had some level of missing information. Researchers started working with the management and staff of the perioperative unit in 2014 to develop a more systematic, long-term approach for improving patient handoffs from the operating room (OR) to the post-anesthesia care unit (PACU). Knowing that a checklist and one-time training wouldn’t produce sustainable change, they created a plan with six stages: 1) preparing, 2) launching, 3) adjusting, 4) boosting, 5) formalizing, and 6) refreshing. The handoff project proved to be a success at reducing the number of handoffs with missing or inaccurate information, and the team has been able to sustain the improvements.