Study: 30% of Medical Errors Due To Poor Communication

A new study reveals how crucial shift change communication can be to a patient’s hospital experience. Health care centers could cut the risk of serious adverse events by 30 percent and other medical errors by 25 percent with better shift change communication, according to Harvard Researcher Dr. Amy Starmer.

Study on reducing medical errors

The study, published in the New England Journal of Medicine on November 6th, involved nearly 10,740 patients at multiple centers in North America. The lead site was Boston’s Children Hospital and data was coordinated at Brigham and Women’s Hospital, with other participating centers including:

• Benioff Children’s Hospital, University of California San Francisco
• Cincinnati Children’s Hospital Medical Center, University of Cincinnati
• Doernbecher Children’s Hospital, Oregon Health Sciences University
• The Hospital for Sick Children, University of Toronto
• Lucile Packard Children’s Hospital, Stanford University
• Primary Children’s Hospital, University of Utah
• St. Louis Children’s Hospital, Washington University St. Louis
• St. Christopher’s Hospital for Children, Drexel University
• Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences

At each hospital, patient handoffs were monitored and assessed over the course of six months. Over the next six months, residents were trained on the new “I-PASS” handoff process and continually monitored for signs of progress. The study largely focused on inpatient pediatric care, but it’s believed the findings will transfer to other departments.

After the introduction of I-PASS, the number of medical errors and preventable adverse events decreased from 4.7 to 3.3 errors per 100 admissions – a 30 percent reduction. By definition, adverse events occur in hospitals when patient injuries are unintentionally caused by medical intervention, rather than the underlying medical condition.

Examples of “preventable adverse medical events” may include:

• Wrong surgery (site, patient, or procedure)
• Foreign objects left inside patient after surgery
• Transplant or blood incompatibility
• Reaction to known allergen
• Administering incorrect medication or dosage
• Transmission of infections
• Trauma (falls, burns)
• Deep vein thrombosis
• Pressure ulcers

What is I-PASS?

Combining medical records, oral conversations, and formal notes into an “I-PASS Handoff Bundle” that was passed around between shifts greatly improved patient care and safety.

The bundles included the following information:

• Illness severity (the patient’s condition)
• Patient history (issues that factor into the patient’s condition)
• Action list (what needs to be done to provide effective patient care)
• Situation awareness (contingency planning for what might occur), and
• Synthesis by receiver (asking questions to show the material was understood).

Best of all, the new program did not affect time spent with patients or place a burden on the medical workers; implementation of I-PASS actually increased medical workers’ satisfaction.

More hospitals expected to join the pilot program

Early adopters expressed great enthusiasm about the possibility of implementing handoff improvement programs at hospitals across the country. “It’s tremendously exciting to finally have a comprehensive and rigorously tested training program that has been proven to be associated with safer care and that meets this need for our patients,” said Dr. Starmer.

However, others expressed healthy skepticism. John Birkmeyer of Dartmouth-Hitchcock Health in New Hampshire said that, while he was impressed with the study findings, it’s not a given that the findings are “generalized or durable.” Results from enthusiastic study participants may be different from “much more apathetic” hospitals, he says. How the findings translate to more sweeping improvement in the number of medical errors remains to be seen.

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