Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program

Abstract

Background: Poor quality handoffs have been identified as a major patient safety issue. In residency programs, problematic handoffs may be an unintended consequence of duty-hour restrictions, and key data are frequently omitted from written handoffs because of the lack of standardization of content.

Objective: Determine whether an intervention that facilitates face-to-face communication supported by an electronic template improves the quality and safety of handoffs.

Design: Before-after trial.

Participants: Thirty-nine interns providing nighttime coverage over 132 intern shifts, representing ∼9,200 handoffs.

Interventions: Two interventions were implemented serially-an alteration of the shift model to facilitate face-to-face verbal communication between the primary and nighttime covering physicians and an electronic template for the day-to-night handoff.

Measurements: Overall satisfaction and handoff quality were measured using a survey tool administered at the end of each intern shift. Written handoff quality, specifically the documentation of key components, was also assessed before and after the template intervention by study investigators. Interns used the survey tool to report patient safety events related to poor quality handoffs, which were validated by study investigators.

Results: In adjusted analyses comparing intern cohorts with similar levels of training, overall satisfaction with the new handoff processes improved significantly (p < 0.001) post intervention. Verbal handoff quality (4/10 measures) and written handoff quality (5/6 measures) also improved significantly. Study investigators also found significant improvement in documentation of key components in the written handoff. Interns reported significantly fewer reported data omissions (p = 0.001) and a non-significant reduction in near misses (p = 0.056), but no significant difference in adverse events (p = 0.41) post intervention.

Conclusions: Redesign of shift models common in residency programs to minimize the number of handoffs and facilitate face-to-face communication, along with implementation of electronic handoff templates, improves the quality of handoffs in a learning environment.

Figure 1

The written sign-out template before (a) and after (b) the electronic template intervention. Displayed here is the electronic documentation system, which links to the provider order entry system and the hospital’s online medical record (webOMR); see the upper right corner of a and b for the location of these links. The larger text boxes featured at the top of a and b are where the teams keep their admission history and physicals for the patient, and the smaller text boxes at the bottom are where the teams document their written sign-outs. Before the intervention, the template was very simple, with the subheading “To do” for each text box. After the intervention, the template subheadings are specific, directing learners about what type of information should be documented in the sign-out.

Figure 2

Timing of data collection periods and interventions over two academic years.