Reducing Handoff Communication Failures and Inequities in Healthcare

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(OAKBROOK TERRACE, Illinois, August 22, 2024) - Inspiring studies related to two common sources of adverse events in healthcare - handoff communication failures, and bias and inequities in care - are featured in the August 2024 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS).

Handoff Communication Failures

Communication failures are among the most frequent causes of harmful medical errors. An estimated 67% of communication errors relate to handoffs (the time when patient care responsibility transitions from one provider to another).

A research team at The University of Texas MD Anderson Cancer Center, Houston, implemented an organization-wide initiative to improve handoffs and implement an evidence-based handoff tool across all inpatient services. I-PASS stands for illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis by receiver. The I-PASS tool, designed to standardize handoff documentation, was built into the electronic health record (EHR).

Staff received training on the tool and compliance was monitored using a customized dashboard. Champions were responsible for the rollout of I-PASS in their respective services. Pre- to post-pandemic results improved: Handoff adherence increased from 41.6% in 2019 to 70.5% in 2022, and safety culture scores on handoff favorability rose from 38% in 2018 to 59% in 2022.

Bias and Inequities in Care

Adverse events occur in almost one out of every four hospital admissions, with a quarter of cases identified as preventable. Root cause analysis teams in healthcare systems across the country investigate adverse events, identify root causes and devise corrective action plans. However, few frameworks exist to incorporate equity into this event analysis.

A quality improvement initiative introduced equity tools during a two-hour interactive, case-based training across 11 acute care facilities at NYC Health + Hospitals, New York. The training featured a visual aid, referred to as the Patient Equity Wheel, which facilitated comprehensive and robust health equity discussions. The Patient Equity Wheel compiles a list of equity categories, including internal, external, and organizational dimensions of equity.

A pre- and post-survey assessed knowledge and comfort embedding equity in patient safety event analysis, and measured discomfort or distress during the training. Findings revealed an increase in participant knowledge and level of comfort after training. Post-training feedback noted that tools were being used across the system in various stages of event analysis and improved health equity conversations.

"These two studies from the August 2024 issue of The Joint Commission Journal on Quality and Patient Safety should inspire hospital leaders working to prevent patient harm, whether by strengthening handoff communications or embedding equity into root cause analysis," says Elizabeth (Liz) Mort, MD, MPHA, vice president and chief medical officer, The Joint Commission. "These institutions are making real-world changes to help improve patient safety and quality of care for all patients. I hope others follow their lead."

Also featured in the August issue are:

• An Interview with Eduardo Salas, PhD (individual recipient of 2023 John M. Eisenberg Patient Safety and Quality Award)
• Screening and Intervention to Prevent Violence Against Health Professionals from Hospitalized Patients: A Pilot Study (Tufts Medical Center, Boston)
• Evaluating Real-World Implementation of INFORM (Improving Nursing Home Care through Feedback on Performance Data): An Improvement Initiative in Canadian Nursing Homes (cohort of 26 nursing homes in British Columbia, Canada)
• Improving Appropriate Use of Peripherally Inserted Central Catheters Through a Statewide Collaborative Hospital Initiative, a Cost-Effectiveness Analysis (The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Michigan)
• Standardizing the Dosage and Timing of Dexamethasone for Postoperative Nausea and Vomiting Prophylaxis at a Safety-Net Hospital System (Case Western Reserve University-MetroHealth System, Cleveland)
• Racial/Ethnic Disparities in Peripartum Pain Assessment and Management (Cedars-Sinai Medical Center, Los Angeles)

For more information, please visit the JQPS website.

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Note for editors

The articles are "Enhancing Implementation of the I-PASS Handoff Tool Using a Provider Handoff Task Force at a Comprehensive Cancer Center," by Maria C. Franco Vega, MD; Mohamed Ait Aiss, ME; Marina George, MD; Lakeisha Day, DMSc, PA-C; Anayo Mbadugha, DMSc, PA-C; Katie Owens, MBA, MHA; Colin Sweeney, BS; Son Chau, BA; Carmen Escalante, MD; and Diane C. Bodurka, MD, MPH and "A System-Wide Strategy to Embed Equity into Patient Safety Event Analysis," by Komal Chandra, PhD; Mariely Garcia; Komal Bajaj, MD; Surafel Tsega, MD; Joseph Talledo, MS; Daniel Alaiev, BBA; Peter Alarcon Manchego, MD; Milana Zaurova, MD; Hillary Jalon, MS; Eric Wei, MD; and Mona Krouss, MD. The article appears in The Joint Commission Journal on Quality and Patient Safety (JQPS), volume 50, number 8 (August 2024), published by Elsevier.

The Joint Commission Journal on Quality and Patient Safety

The Joint Commission Journal on Quality and Patient Safety (JQPS) is a peer-reviewed journal providing healthcare professionals with innovative thinking, strategies and practices in improving quality and safety in healthcare. JQPS is the official journal of The Joint Commission and Joint Commission Resources, Inc. Original case studies, program or project reports, reports of new methodologies or the new application of methodologies, research studies, and commentaries on issues and practices are all considered.