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Neonatal intensive care unit handoffs: a pilot study on core elements and epidemiology of errors

Journal of Perinatology volume 34, pages 149–152 (2014)Cite this article

Subjects

Abstract

Objective:

To define the core data elements of a neonatal intensive care unit (NICU) handoff compare NICU residents’ written and verbal handoff data with real-time, auto-populated data and identify the epidemiology of handoff errors.

Study Design:

We defined nine core data elements for a NICU patient handoff. We then compared residents’ written and verbal handoffs against real-time, auto-populated data for each core element.

Result:

A total of 101 NICU patient handoffs (31 unique patients) were analyzed. Per patient, residents made more written errors for infants in critical-care beds than for infants in step-down beds (2.33 vs 1.67, P=0.04). Replacing residents’ written handoffs with the gold-standard, auto-populated data would have prevented 92% of written errors.

Conclusion:

NICU infants are subjected to many handoff errors. Sicker infants are at higher risk for error. Auto-population can reduce written handoff errors and allow residents more time for training and educational opportunities.

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References

  1. Borowitz SM, Waggoner-Fountain LA, Bass EJ, Sledd RM . Adequacy of information transferred at resident sign-out (in-hospital handover of care): a prospective survey. Qual Saf Health Care 2008; 17 (1): 6–10.

    Article  CAS  Google Scholar 

  2. McSweeney ME, Lightdale JR, Vinci RJ, Moses J . Patient handoffs: pediatric resident experiences and lessons learned. Clin Pediatr (Phila) 2011; 50 (1): 57–63.

    Article  Google Scholar 

  3. Common Program Requirements. Available at: http://www.acgme-2010standards.org/pdf/Common_Program_Requirements_07012011.pdf Accessed 30 October 2012.

  4. AHRQ. Patient safety primers: handoffs and signouts. Available at: http://www.psnet.ahrq.gov/primer.aspx?primerID=9 Accessed 30 October 2012.

  5. Arora V Hospital handoffs for intern orientation Available at: http://www.slideshare.net/MergeLab/hospital-handoffs-for-intern-orientation Accessed 30 October 2012.

  6. Arora V, Johnson J . A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf 2006; 32 (11): 646–655.

    Article  Google Scholar 

  7. Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S . Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med 2009; 4 (7): 433–440.

    Article  Google Scholar 

  8. Horwitz LI, Moin T, Green ML . Development and implementation of an oral sign-out skills curriculum. J Gen Intern Med 2007; 22 (10): 1470–1474.

    Article  Google Scholar 

  9. Horwitz LI, Parwani V, Shah NR, Schuur JD, Meredith T, Jenq GY et al. Evaluation of an asynchronous physician voicemail sign-out for emergency department admissions. Ann Emerg Med 2009; 54 (3): 368–378.

    Article  Google Scholar 

  10. DeRienzo CM . The Duke GME Patient Safety and Quality Council. Am J Med Qual 2012; 27 (Suppl 2): 30S–31S.

    Google Scholar 

  11. DeRienzo CM, Frush K, Barfield ME, Gopwani PR, Griffith BC, Jiang X et al. Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements. Acad Med 2012; 87 (4): 403–410.

    Article  Google Scholar 

  12. Kitch BT, Cooper JB, Zapol WM, Marder JE, Karson A, Hutter M et al. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf 2008; 34 (10): 563–570.

    Article  Google Scholar 

  13. Dhingra KR, Elms A, Hobgood C . Reducing error in the emergency department: a call for standardization of the sign-out process. Ann Emerg Med 2010; 56 (6): 637–642.

    Article  Google Scholar 

  14. Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH . International Standards for a Safe Practice of Anesthesia 2010. Can J Anaesth 2010; 57 (11): 1027–1034.

    Article  Google Scholar 

  15. Sharit J, McCane L, Thevenin DM, Barach P . Examining links between sign-out reporting during shift changeovers and patient management risks. Risk Anal 2008; 28 (4): 969–981.

    Article  Google Scholar 

  16. ACOG committee opinion. Number 367. Communication strategies for patient handoffs. Obstet Gynecol 2007; 109 (6): 1503–1505.

    Article  Google Scholar 

  17. Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM . Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med 2006; 1 (4): 257–266.

    Article  Google Scholar 

  18. Kemp CD, Bath JM, Berger J, Bergsman A, Ellison T, Emery K et al. The top 10 list for a safe and effective sign-out. Arch Surg 2008; 143 (10): 1008–1010.

    Article  Google Scholar 

  19. Singer JI, Dean J . Emergency physician intershift handovers: an analysis of our transitional care. Pediatr Emerg Care 2006; 22 (10): 751–754.

    Article  Google Scholar 

  20. Mistry NK, Toulany A, Edmonds JF, Matlow A . Optimizing physician handover through the creation of a comprehensive minimum data set. Healthc Q 2010; 13 (Spec no.): 102–109.

    Article  Google Scholar 

  21. Palma JP, Sharek PJ, Longhurst CA . Impact of electronic medical record integration of a handoff tool on sign-out in a newborn intensive care unit. J Perinatol 2011; 31 (5): S83–S84.

    Article  Google Scholar 

  22. Riesenberg LA, Leitzsch J, Little BW . Systematic review of handoff mnemonics literature. Am J Med Qual 2009; 24 (3): 196–204.

    Article  Google Scholar 

  23. Riesenberg LA, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C et al. Residents’ and attending physicians’ handoffs: a systematic review of the literature. Acad Med 2009; 84 (12): 1775–1787.

    Article  Google Scholar 

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Acknowledgements

We thank Dr David Tanaka for help in preparing statistical analyses and Peter Hoffmann for help in manuscript preparation. We also thank Duke’s residents for their support of our work and the excellent care they provided for our critically ill neonates. This work was funded by both the Jean and George Brumley Jr. Neonatal–Perinatal Research Institute and by a grant through the Duke Graduate Medical Education Innovation Program for which Dr Ferranti is the Principal Investigator.

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Authors and Affiliations

  1. Division of Neonatology, Department of Pediatrics, Duke University Hospital, Durham, NC, USA

    C DeRienzo, R Lenfestey & R Goldberg

  2. Duke Health Technology Solutions, Duke University Health System, Durham, NC, USA

    M Horvath

  3. Duke University Health System and Duke University Hospital, Durham, NC, USA

    J Ferranti

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  1. C DeRienzo
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  2. R Lenfestey
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  4. R Goldberg
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Correspondence to C DeRienzo.

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Competing interests

Dr DeRienzo has received honoraria from academic medical centers to speak on quality improvement and patient safety initiatives, and compensation from Doximity. The other authors declare no conflict of interest.

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DeRienzo, C., Lenfestey, R., Horvath, M. et al. Neonatal intensive care unit handoffs: a pilot study on core elements and epidemiology of errors. J Perinatol 34, 149–152 (2014). https://doi.org/10.1038/jp.2013.146

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