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Large-scale implementation of the I-PASS handover system at an academic medical centre
  1. David M Shahian1,2,
  2. Kayla McEachern3,
  3. Laura Rossi3,
  4. Roger Gino Chisari4,
  5. Elizabeth Mort5,6
  1. 1Center for Quality and Safety and Department of Surgery, Massachusetts General Hospital and Massachusetts General Physicians Organization, Boston, Massachusetts, USA
  2. 2Harvard Medical School, Boston, Massachusetts, USA
  3. 3Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians Organization, Boston, Massachusetts, USA
  4. 4Norman Knight Center for Clinical and Professional Development, Massachusetts General Hospital, Boston, Massachusetts, USA
  5. 5Center for Quality and Safety and Department of Medicine, Massachusetts General Hospital and Massachusetts General Physicians Organization, Boston, Massachusetts, USA
  6. 6 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr David M Shahian, Massachusetts General Hospital and Massachusetts General Physicians Organization, Center for Quality and Safety and Department of Surgery, Boston, MA 02114, USA; dshahian{at}partners.org

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Introduction

Problem description

In 2012, Massachusetts General Hospital (MGH) safety culture survey scores for handovers and transitions of care, though similar to the national median, were the lowest among all domains. Furthermore, based on safety reports and resident surveys, deficient handovers were not infrequently associated with preventable errors and adverse events. Although virtually all departments and divisions had some handover policy, there was no systematic, standardised, institution-wide approach.

These findings were also concerning given the educational mission of MGH, as there are Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements (VI.B.2 and VI.B.3) for resident competency in ‘effective, structured handover processes’.1 A previous study of MGH residents demonstrated that handovers often lacked important elements, and 59.4% of respondents reported that problematic handovers had contributed to major or minor patient harm.2

These considerations were the proximate stimulus for the MGH Center for Quality and Safety (CQS) to implement a comprehensive handover initiative using the I-PASS system.3–5

Available knowledge

The handover problem

Handovers of patient care responsibility are ubiquitous in healthcare, affecting all practitioners in a myriad of different scenarios: nurses, residents, attending physicians and therapists; shift change, weekend coverage, night floats, off-service transitions, cross-service or cross-venue transfers; and inpatient–outpatient transitions.6 ,7 However, despite their central role in assuring safe and high-quality care, evidence from multiple sources demonstrates that healthcare handovers are often flawed or inadequate. Handoffs and transitions of care are typically among the lowest scoring domains in national summaries of Agency for Healthcare Research and Quality (AHRQ) safety culture survey scores (47% positive in 2014),8 and communication failures are a common cause of Joint Commission Sentinel Events9 and malpractice claims.10–12

Handovers have not evolved to meet the needs of contemporary practice

Healthcare handovers have always been suboptimal. However, their inadequacy has become more apparent and consequential in recent years, and the attention focused on them has commensurately increased,13–15 …

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