Project Summary

Because communication and handoff failures are a root cause of two-thirds of “sentinel events”– serious, often fatal preventable adverse events in hospitals – improving handoffs has been identified by AHRQ and the Joint Commission as a priority in nationwide efforts to improve patient safety. Comparative Effectiveness Research on handoff tools and processes has identified specific strategies to improve handoffs and reduce medical errors:

1. Team training;
2. Verbal mnemonics
3. Use of written/computerized tools to supplement verbal sign-outs.

Objectives

To accelerate residents’ use of CER-based handoff practices and improve patient safety, we are implementing the three inventions above as a Resident Handoff Bundle (RHB) in eight pediatric hospitals in the United States and Canada.