Implementation of Standardized Handoff Strategies to Decrease Communication Errors Associated With Memorized Data Loss and Incorrect Orders in the Long-Term Ventilated Patient

Abstract

Background:

Inadequate hand-off communication contributes to an estimated 80% of serious medical errors. Adverse events such as care omissions, inappropriate orders, inefficacy of work and patient harm can be attributed to miscommunication during hand-offs. This project aims to improve the hand-off communication of respiratory therapists at a pediatric facility by implementing specific hand-off strategies. The literature reviewed indicates performing hand-offs at the bedside and creating standardized expectations for staff to follow improves both communication and safety.

Methods:

An IRB approved study to improve hand-off communication amongst respiratory therapists with specific implementations for this initiative including: the creation of a team of role models, increasing staff education through skills fairs with knowledge based assessments, a specifically designed electronic medical record (EMR) hand-off tool, changing the location for staff to perform the hand-off to the patient’s bedside and providing staff EMR access. Chi-squared was used for statistical analysis.

Results:

Post-data analysis showed 100% compliance with respiratory therapists visualizing the patient and the ventilator during hand-offs while following the new standards. Prior to project implementation 6 ventilator related errors were reported through the Real Learning Systems incident reporting system. Post project implementation, 0 ventilator related errors were reported (P = .40). Staff perception that errors were “never” found increased from 0% (n = 17) before implementation to 33.3% (n = 12) after implementation (P = .01). No increases in overall staff overtime utilization were noted. An 11% reduction of incremental overtime utilization was noted post analysis which may indicate the new hand-off standards were actually more efficient than previous practices. Pre and post staff satisfaction surveys showed an improved perception of patient safety.

Conclusions:

Hand-off communications directly affects patient safety. Standardizing the critical content to be communicated while directly visualizing the patient during the hand-off process can decrease the number of ventilator incident discrepancies and help prevent data omission errors. Standardizing hand-off communication to promote patient safety can be achieved without increasing handoff duration. Disclosures: William Hearst Foundation