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Systematic Handoffs to Improve Patient Outcomes and Resident Satisfaction: a Single-Center Observational Study

  • Navneet SinghEmail author
  • Christine Yun
  • Michelle Likhtshteyn
  • Nirmal Pathak
  • Steven Massad
  • Rovie Mesola
  • Miguel Ramirez
Concise Research Reports
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INTRODUCTION

Medical residents are at the forefront of patient care in many healthcare institutions and thus an integral part of ensuring safe and efficient handoffs. Recent studies have shown that an increase in patient handoffs directly contributes to increased adverse medical events.1, 5 Implementation of an innovative standardized handoff procedure minimizes medical errors without significantly disrupting workflow.6 The purpose of this study was to prospectively assess the belief that a standardized handoff procedure at our institution would improve resident satisfaction while decreasing adverse events.

METHODS

Residents were asked to track non-lethal adverse events for 6 weeks, which could have been prevented with a more efficient handoff, e.g., an inappropriate altered mental status workup on a patient with known dementia that was not documented and not conferred in the handoff. We then created a standardized handoff procedure with specific details that needed to be conveyed...

Notes

Acknowledgments

The investigators would like to acknowledge Jay Thompson for his tireless work in revising the handoff software to accommodate our study. We would also like to thank the internal medicine residents who devoted their limited time to participation in this study.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

References

  1. 1.
    Abraham J, Kannampallil T, Patel VL. A systematic review of the literature on the evaluation of handoff tools: implications for research and practice. J Am Med Inform Assoc. 2013;21(1):154–162.CrossRefPubMedGoogle Scholar
  2. 2.
    The Joint Commission. Inadequate hand-off communication. Sentinel Event Alert. 2017; 58:1-6Google Scholar
  3. 3.
    Revere, A., Eldridge, N. Joint Commission National Patient Safety Goals for 2008. Topics in Patient Safety. 2008:12(1):1-4.Google Scholar
  4. 4.
    The Joint Commission Center for Transforming Healthcare. Improving Transitions of Care: Hand-Off Communications. 2014.Google Scholar
  5. 5.
    Kitch BT, Cooper JB, Zapol WM, et al. Handoffs Causing Patient Harm: A Survey of Medical and Surgical House Staff. Jt Comm J Qual Patient Saf. 2008;34(10):563-570d.CrossRefPubMedGoogle Scholar
  6. 6.
    Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803–1812.CrossRefPubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Navneet Singh
    • 1
    Email author
  • Christine Yun
    • 1
  • Michelle Likhtshteyn
    • 1
  • Nirmal Pathak
    • 1
  • Steven Massad
    • 1
  • Rovie Mesola
    • 1
  • Miguel Ramirez
    • 1
  1. 1.Department of Internal Medicine SUNY Downstate Medical CenterBrooklynUSA

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