The first issue Landrigan and his team discovered was a lack of training in how to conduct handoffs. “Sure enough, when the whole bundle was put in place, the team working on HAIs found that rates for those kinds of infections fell 80%.
IPASS NURSING SERIES
“They’d say, ‘Let’s not just do handwashing, but let’s also optimize the use of sterile precautions when putting in catheters, and let’s implement daily checklists to try to minimize the amount of time catheters are in place’ … a series of little things with some evidence behind each of them” to maximize the end results, Landrigan says. Specifically, the team observed that HAI prevention wasn’t going to happen with one silver-bullet intervention, but rather with bundles of smaller interventions to get more bang for the buck. The I-PASS team took lessons learned from other patient safety interventions that were having an impact in the industry, such as efforts to eliminate hospital-acquired infections (HAI). It was pretty clear early on, the dangers there.” We realized we had to develop systems to solve handoff problems. As we started implementing safer work schedules that eliminated these marathon shifts, handoffs between physicians working shorter shifts became more common. “I started working on trying to understand the risks of long work hours early in my career. “I trained in an era of no shift length limits,” he says, noting it wasn’t uncommon for physicians to be on for 36 hours or more at the time. Chris Landrigan, chief of general pediatrics at Boston Children’s Hospital, began looking into the issue of patient handoffs as a pediatric hospitalist. A 75% reduction in both major and minor patient harm events due to miscommunications.
3 million major and minor patient harm events prevented.100 million handoffs using the I-PASS solution.hospitals, the I-PASS Institute and the I-PASS Study Group have seen significant successes over the past decade: To combat these risks, I-PASS has developed methods for improving communication during transitions-and the I-PASS Institute has just celebrated its fifth year using its process. In addition, handoff communication errors can lead to financial costs and reputational harm. The Joint Commission has found that communication mistakes made during patient handoffs are a root cause for more than two-thirds of the most serious errors that befall patients. Patient handoffs present an especially high risk for communication errors. Handoff process marks five years of successįailures in communication frequently prompt medical errors, which make up one of the leading causes of death in the United States, behind heart disease and cancer.
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