Implementation of Standardized Patient Handoff on a Medical Surgical Inpatient Unit

Abstract

Problem: Poor communication within a health care organization was cited as a main cause of error and poor patient outcomes especially during transition of care. An estimated 80% of medical errors in patient care are related to miscommunication in handoff. Inadequate patient handoff communication can lead to delay in treatment or hospital discharge. Improved communication with standardized handoff has shown to have a positive correlation to conveying necessary information, preventing errors, and improve patient safety. The Report and Learn (RL) is an incident reporting system that monitors patient safety events at a community hospital. Approximately one to six safety incidents were reported weekly by the inpatient medical/surgical unit. Communication delivery may have accounted for two to six incidents of error or near error in monthly safety reports. Evidenced reviewed showed that a structured handoff tool can help to promote sufficient input from the nurse to communicate pertinent patient care information at change of shift to improve giver to receiver communication and prevent error. Purpose: The purpose of this project was to implement and evaluate the effectiveness of a standardized handoff tool for nursing shift report to improve communication and reduce medical errors. Evidence reviewed supports the I-PASS (Illness severity, patient summary, action list, situation awareness and contingency plan, and synthesis by the receiver) handoff tool for this implementation. Methods: This was a quality improvement (QI) project that measured percent errors related to poor handoff on the medical/surgical unit. The medical/surgical unit has 36 beds with 35 full time nursing staff. The QI project collected data on communication with use of I-PASS over a 15-week period. STANDARDIZED PATIENT HANDOFF 3 Results: Findings indicated a 69% staff education of use with the I-PASS tool. There was a 23% decrease in error over the course of project implementation and a 50% decrease from start of project to completion. Conclusion: The I-PASS tool was useful and relevant to decreasing communication error and patient safety events. Opportunity to further expand use of the I-PASS tool to other units would further validate the tool’s effectiveness.