SickKids hospital using new tool to reduce medical errors
TORONTO-Terms such as “watcher” are being taught to residents caring for patients at the Hospital for Sick Children (SickKids).
“When we’re hearing at handover about the patients, you have a lot going on that you’re thinking about at once so, it’s really helpful to have words that flag us. For example, the word watcher is one that we bring up when it’s a patient that we need to have an extra close eye on, ” said Jenny Smith, chief resident at SickKids.
The change in language follows the hospital’s involvement with a North American study examining the benefits of a communications model known as I-PASS.
It combines verbal and written tools to helps doctors focus on critical information that needed to be shared during shift changes.
“We knew that attention to handoff was growing because of resident duty hours and is a tired doctor a safe doctor and so we really wanted to get involved and we are also apart of a research network,” said Dr. Trey Coffey, medical officer for patient safety, staff pediatrician and project investigator at SickKids.
The nine hospitals involved had outcomes monitored for a six month period, during, and after the implementation of I-PASS.
That information included medical errors, quality of written materials and information shared verbally during shift changes.
The study, appeared online in the Nov. 6 issue of the New England Journal of Medicine, found the I-PASS Handoff Bundle led to a 23 per cent reduction in the incidence of medical errors and a 30 per cent drop in injuries due to medical errors.
Statistics for individual hospitals were not released.
“We need structure and a format for handoff and we need specific training. Most of the information that we share is what we call structured common sense,” Dr. Coffey said. “It’s the kind of information that doctors think is important to share anyway but what we learned from the study was that without specific structure and training some of those important things weren’t being shared reliably.”
The study was led by doctors at Boston Children’s Hospital and funded, in part, by the U.S. Department of Health and Human Services, The Agency for Healthcare Research, as well as the SickKids Foundation.
“One thing that we do know when we analyze serious errors in all hospitals is the most common route cause that comes out is communication problems. One of the things I’m most proud of is the culture change it brought about,” said Dr.Coffey
The I-PASS model is now being implemented in some form in specialties at SickKids including Pediatric Medicine and Cardiology as well at other pediatric hospitals in Canada.