BOSTON — Researchers at Boston Children’s Hospital say they have devised a new system of shift-to-shift patient handoffs that significantly reduces medical errors.
After introducing the system on two inpatient units at the hospital, the researchers found that preventable errors declined by more than half over three months, they announced Tuesday.
Patient handoffs at shift changes when new doctors and nurses come on duty can be chaotic, often done in noisy hallways with multiple distractions, Dr. Amy Starmer, associate scientific researcher at Boston Children’s and lead author of a study published in the Journal of the American Medical Association told The Boston Globe.
The researchers trained doctors on team-based communication strategies and introduced an acronym to help them remember key points to cover when discussing patients. They encouraged people to gather as a team, including senior physicians and doctors in training, to discuss patient care together in a quiet space, rather than the busy hallway.
On one unit, they also introduced a computerized tool to create printouts with key patient information and to prompt doctors whose shift was ending to fill out a to-do list for those coming on.
“We couldn’t do just one small, little thing and expect to have an impact,” Starmer said.
The researchers reviewed patient care before and after the system was introduced, and they tracked physician behavior. The new process resulted in doctors exchanging more complete information but did not require additional time, the study found. Preventable medical errors fell to 1.5 per 100 admissions, from a rate of 3.3.
Researchers are now studying the new procedure at nine pediatric centers around the country, with a $3 million grant from the U.S. Department of Health and Human Services.