• Implementation of a Handoff Report Tool Among Trauma Intermediate Care Nurses

      Fortune, Shanna; Bundy, Elaine Y. (2020-05)
      Problem and Purpose: An estimated 80% of serious errors and sentinel events are attributable to miscommunication during patient handoffs. Since 2010, the JCAHO has required that during transitions in care, healthcare providers engage in handoff communication between the giver and receiver of hospitalized patients. Inadequate patient handoff communication remains a key contributor to medical errors, preventable adverse events, and sentinel events. The illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis by receiver (I-PASS) method was created with use of a tool to improve handoff communication practices. The handoff tool was designed to decrease medication errors and enhance the safety and quality of patient care. Among nurses working in a multi-trauma intermediate care unit, a standardized patient handoff process with the critical elements of communication was lacking at a tertiary academic hospital in the Mid-Atlantic region. The nurse manager of a trauma intermediate care unit reported large nursing staff turnover and concerns about novice staff members’ handoff communication effectiveness. With high acuity and a complex patient population, effective handoff is essential to maintaining patient safety as well as minimizing omissions in care and potential errors. Methods: The purpose of this Doctor of Nursing Practice quality improvement project was to implement and evaluate the I-PASS handoff tool for perceived handoff report communication among nurses. Compliance with the verbal communication and written report tools were audited weekly. A pre/post perceived handoff communication survey was also distributed prior to and after the 15-week project period. Results: Findings indicated that staff compliance with the I-PASS handoff report tool reached or exceeded the goal of 75% from week five to week 14. When using the handoff report tool, perceived handoff communication increased significantly by 9% post implementation (p < 0.05). The medication error event rate declined by 47% during the implementation period. Conclusions: The I-PASS handoff report tool improved perceived handoff communication among nurses. Subsequent quality improvement projects are recommended to evaluate the use of adapted unit-specific I-PASS handoff report tools to further validate the method’s effectiveness and potential to improve medication-related and patient safety events.
    • Implementation of Standardized Patient Handoff on a Medical Surgical Inpatient Unit

      Delgado, Jamie L.; Bode, Claire (2022-05)
      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.
    • Interunit Implementation of a Standardized Nurse Handoff Method in Cardiac Surgery

      Burnham, Ashley; Akintade, Bimbola F. (2019-05)
      Background: Handoff is inevitable and creates the potential for error or injury. Communication errors have been associated with hundreds of patient deaths and upwards of one billion dollars in cost annually. A method accounting for illness severity, patient summary, action list, situational awareness and contingency plans, and synthesis by receiver, called I-PASS, was developed to provide a handoff framework resulting in improved communication, reduced errors, and improved patient safety. Local Problem: The cardiac surgery patient population ranges in complexity from routine procedures to those who requiring some of the most complex procedures and management. There was no standard in place at this institution for nurse handoff of patients between the Cardiac Surgery Intensive Care and Telemetry units. Interventions: The I-PASS method was implemented at a tertiary academic medical center, over 13 weeks, to evaluate the effects on the nurse satisfaction, quality, handoff duration, and usability during nurse handoff between the Cardiac Surgery Intensive Care Unit and Telemetry units. This quality improvement project utilized the Plan-Do-Study-Act framework and included patients selected for unit transfer pre or post-intervention. Exclusion criteria included rapid response or emergent patient transfer. The I-PASS method was adapted for cardiac surgery. Staff education occurred during huddles. A resource sheet, modified system usability score and nurse satisfaction surveys were distributed to transferring and receiving nurses. Surveys were collected from each nurse and handoff duration documented. Results: The I-PASS method was liked by 39.5% of nurses. I-PASS reduced unnecessary or erroneous information reported by 41.7% of nurses. Longer handoff duration was perceived by 41.7% of nurses. I-PASS averaged a mean usability score of 59.36 and a mean handoff duration of 11 minutes. Conclusions: The current I-PASS method cannot be recommended. Modifications should be made to the nurse handoff method. Additional studies are recommended to further evaluate the impact of the I-PASS method during nurse handoff.