Background: Handoff miscommunications are a leading source of medical errors. Medical error and adverse event rates decreased following implementation of the I-PASS handoff program (a bundled intervention using a structured mnemonic, I-PASS, and other initiatives to sustain implementation) in a pediatric research trial. Whether I-PASS can be implemented in settings outside academic pediatric institutions is [...]

Background: Handoff miscommunications are a leading source of medical errors. Medical error and adverse event rates decreased following implementation of the I-PASS handoff program (a bundled intervention using a structured mnemonic, I-PASS, and other initiatives to sustain implementation) in a pediatric research trial. Whether I-PASS can be implemented in settings outside academic pediatric institutions is [...]

Background: Hospitalists increasingly rely upon electronic handoff tools to communicate important patient care information. Our institution transitioned from a paper/verbal handoff process to a completely electronic system in April 2017 for day-to-night patient care handoff. In the fall of 2016, the same system had been adopted for end-of-week service change. Purpose: This study set out [...]

Background: Standardizing inter-shift handoff procedures enhances continuity of care and quality with an associated reduction in preventable medical errors. This is particularly relevant in the inpatient oncology population where patients have a relatively high morbidity/mortality compared to the general inpatient population. With increasing handoffs due to work hour restrictions, and rising utilization of multidisciplinary teams, [...]

Background: Transitions of care are critical to maintaining patient safety and decreasing adverse events, but they remain a complex process with many pitfalls. Electronic Medical Record (EMR) based handoffs can enhance communication by centralizing content for serial handoffs between providers, facilitating real-time updates and automatically incorporating patient data elements. Over the past several years, much [...]

Background: The high volume of handoffs between the Emergency Department (ED) team and the inpatient team on a daily basis makes this a ripe area for care improvement. Effective, safe and organized transitions facilitate high quality and efficient care, while a dysfunctional process negatively affects patients and practitioners and compounds overall hospital congestion and delays [...]

Background: Medical housestaff must participate in a handoff process when transitioning between rotations on hospital services. During this time, a new team of residents assumes care for multiple patients. A prior study demonstrated that this critical period of transition is associated with increased mortality among hospitalized patients. Methods of improving daily patient handoffs to overnight [...]

Case Presentation: A 28-year-old woman with sickle cell disease and chronic pain who required inpatient care several times yearly presented with worsening nausea, emesis and uncontrolled pain to the emergency department (ED). Symptoms were typical of prior pain crises. The patient followed regularly with a hematologist undergoing monthly red blood cell exchange transfusions. In the [...]