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HANDOFFS: Implementing a handoff bundle cut medical errors and preventable adverse effects at teaching hospital

Boston Children’s Hospital studied the effect of implementation of a resident handoff bundle to improve communications and patient safety on two inpatient units.  The overall rate of medical errors was found to decrease from 33.8 to 18.3 errors per 100 admissions.  The rate of preventable adverse incidents decreased from 3.3 to 1.5 per 100 admissions during the same period.  There was some interesting data on the types of errors and adverse events, too.

Types of Errors and Adverse Events (based on 350 total incidents)

  • 77% medication related
  • 8.3% procedure related
  • 4.3% test related
  • 3.7% falls
  • 3.4% other therapy related
  • 3.2% other incidents

Source: Starmer, A.J., Sectish, T.C., and others.  Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle.  JAMA;310(21):2262-2270, Dec. 4, 2013.  Click here for full text: http://jama.jamanetwork.com/data/Journals/JAMA/929415/joi130091.pdf  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

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