![]() ![]() 15.5 near misses and nonharmful errors per 100 admissions, P<0.001) ( Table 2 ). The handoff project proved to be a success at reducing the number of handoffs with missing or inaccurate information, and the team has been able to sustain the improvements. The rate of near misses and nonharmful medical errors decreased by 21 (19.7 vs. Knowing that a checklist and one-time training wouldn’t produce sustainable change, they created a plan with six stages: 1) preparing, 2) launching, 3) adjusting, 4) boosting, 5) formalizing, and 6) refreshing. Researchers started working with the management and staff of the perioperative unit in 2014 to develop a more systematic, long-term approach for improving patient handoffs from the operating room (OR) to the post-anesthesia care unit (PACU). Leaders noticed that the majority of patient handoffs had some level of missing information. To improve timeliness while maintaining patient safety, Brigham and Women’s Hospital implemented a novel use of eIPASS an ED-to-IP I-PASS handoff tool in its electronic health record for both. Examples of transitions in care include shift changes transfer of responsibility between and among nursing assistants, nurses, nurse practitioners. It includes an opportunity to ask questions, clarify, and confirm. The perioperative unit at Midland Memorial Hospital (MMH) in Texas was in precisely that situation. Handoff The transfer of information (along with authority and responsibility) during transitions in care across the continuum. Second, they struggle to sustain change that’s made. ![]() The problem is two-fold: first, hospital administrators and managers struggle to effectively implement these tools. Despite the development of numerous techniques and tools to improve patient handoffs, we haven’t seen much improvement in reducing medical errors that result from them. ![]()
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