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Children’s Hospital creates system for safe patient handoffs

Researchers map strategy to reduce errors

It happens two or three times a day in hospitals: Doctors hand off their patients to the next shift, sometimes standing in the hallway with their pagers ringing and the frenzy of the hospital swirling around them. Important information about a patient’s condition and treatment needs can get lost in the shuffle, a known cause of medical errors.

On Tuesday, researchers at Boston Children’s Hospital provided some of the first good evidence that a more structured patient handoff improves care. After introducing a new system on two inpatient units at the hospital, the group found that preventable errors declined by more than half over three months.


Patient handoffs have historically been chaotic, shaped by bigger systemic issues and physicians’ ingrained habits, said 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 .

“We couldn’t do just one small, little thing and expect to have an impact,” she said.

The researchers did several things. They 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.

They reviewed patient care before and after, 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.

Patient safety specialists have known for years that patient handoffs were a key area for improvement. They have sharpened their attention in recent years as hospitals have imposed limits on how many hours doctors-in-training can work, to prevent them from working while drowsy. Shorter shifts mean more handoffs and a greater potential for errors in the process.


“What I think has been a challenge is finding effective tools to actually solve the problem,” said Dr. Kedar Mate, vice president at the Institute for Healthcare Improvement, a nonprofit in Cambridge focused, in part, on patient safety.

Mate said the study offers a good example of how to make the necessary changes. Like the study authors, he noted that because the decline in errors was so dramatic it is possible that other factors contributed to the change.

The authors noted that differences in patient populations and in the experience level of physicians in training before and after the introduction of the hand-off tools could have affected the results.

Still, the Children’s Hospital study is “by far the most comprehensive” look at how improved handoffs can reduce harm to patients, Dr. Leora Horwitz, associate professor of medicine at Yale School of Medicine, said in an editorial accompanying the study.

Dr. Christopher Landrigan, research director for the inpatient pediatric service at Boston Children’s and senior author of the study, said one of the most important findings was that doctors spent more time at patients’ bedside after the new system began.

It is not clear exactly why, but Landrigan said he suspects that doctors spent less time running back and forth to the computer to search for patient information.


“They just had it more at their fingertips,” he said.

Starmer said the computerized hand-off tool has been particularly popular and has been adapted to other units at the hospital.

The researchers are now studying the new hand-off procedure at nine pediatric centers around the country, with a $3 million grant from the US Department of Health and Human Services.

Mate said that more hospitals will probably institute programs similar to the one at Children’s, in part because the primary organization that accredits graduate medical education has placed a greater emphasis on patient safety programs and structured communication between physicians in training and other medical professionals.

Implementing the hand-off program does not cost much, beyond doctors’ commitment to do things differently, Mate said. Even if the actual reduction in medical errors is less than the study found, “you would still consider it a worthwhile investment.”

Chelsea Conaboy can be reached at chelsea.conaboy@
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