Changes in Medical Errors after Implementation of a Handoff Program

Abstract

Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

The Impact of Rudeness on Medical Team Performance: A Randomized Trial

“…[28][29][30][31] For example, recent studies estimate that patients are exposed to at least 1 medication error per day 4,32 and report numerous cases of retained surgical items. 4,33 We suspect that 1 major reason for this gap is because many of the improvements were directed at refining systems and technologies 11,14 while neglecting human/relational factors. 4,34 Our results highlight the potential role of human interaction in iatrogenic events, indicating that occurrence of even a mild rudeness can have adverse consequences on the diagnostic and procedural performance of NICU team members.…”

“…2,3,7,8 Although research has tended to focus primarily on patientrelated factors (eg, age, weight), 1, [8][9][10][11] studies suggest that practitioner stressors may also heighten iatrogenic risk. [12][13][14] One such stressor may be rudeness, a relatively mild form of interpersonal aggression or incivility. At least 1 study 3 speculated that such subtle contextual stressors may be linked to iatrogenic events by affecting medical professionals' cognitive processing (at the individual level) and communication processes (at the team level).…”

Year in Review 2014: Patient Safety

“…Starmer et al 18 conducted an interventional study of resident handoffs in 10,740 admissions at 9 hospitals. They measured rates of medical errors, preventable adverse events, miscommunications, and resident workflow.…”

Capsule Commentary on Ratelle et al., Predicting and Communicating Risk of Clinical Deterioration: An Observational Cohort Study of Internal Medicine Residents

“…Further investigation is needed to understand the multiple inter-related factors that impact handoff effectiveness, particularly since standardized handoff procedures have recently been associated with a reduction in medical errors and preventable adverse events when implemented in conjunction with communication training and faculty development. 5 …”