Ipass nursing report sheet11/19/2023 ![]() But over time, the field worked to demonstrate just how preventable those infections really were. Returning to the parallels with successful changes to HAIs, Landrigan notes that earlier on, there was a belief that certain procedures had certain rates of infections, and HAIs were considered an inevitable downside. ![]() ![]() “With that little bit of preliminary data people were more willing to engage, and with academic credentials behind it, it planted the seed for the I-PASS Institute. “Those results looked even better,” says Landrigan. The nine-center study examining the effects of I-PASS across institutions was a huge success. ![]() With the input of medical educators, hospitalists, health services researchers, and quality improvement experts, the pilot bundle was transformed into I-PASS. The single-center pilot study was published in the Journal of the American Medical Association, and this served as the preliminary data for a major grant funded by the U.S. But we did careful measurement on its impact on patient safety, doctor workflows, and on the handoffs themselves, and in every one of those respects, things looked really positive.” When we started out with this idea, people weren’t convinced it would make an impact. “Even building in a few little elements, we saw medical error rates plummet on our units,” says Landrigan. They also thought about elements that would be conducive to a good handoff: the right people in the room, a sufficient level of quiet, and assistance from the electronic health record (which required some help from IT). The first issue Landrigan and his team discovered was a lack of training in how to conduct handoffs. “Sure enough, when the whole bundle was put in place, the team working on HAIs found that rates for those kinds of infections fell 80%. “They’d say, ‘Let’s not just do handwashing, but let’s also optimize the use of sterile precautions when putting in catheters, and let’s implement daily checklists to try to minimize the amount of time catheters are in place’ … a series of little things with some evidence behind each of them” to maximize the end results, Landrigan says. Specifically, the team observed that HAI prevention wasn’t going to happen with one silver-bullet intervention, but rather with bundles of smaller interventions to get more bang for the buck. The I-PASS team took lessons learned from other patient safety interventions that were having an impact in the industry, such as efforts to eliminate hospital-acquired infections (HAI). It was pretty clear early on, the dangers there.” We realized we had to develop systems to solve handoff problems. As we started implementing safer work schedules that eliminated these marathon shifts, handoffs between physicians working shorter shifts became more common. “I started working on trying to understand the risks of long work hours early in my career. “I trained in an era of no shift length limits,” he says, noting it wasn’t uncommon for physicians to be on for 36 hours or more at the time. Chris Landrigan, chief of general pediatrics at Boston Children’s Hospital, began looking into the issue of patient handoffs as a pediatric hospitalist. A 75% reduction in both major and minor patient harm events due to miscommunications.3 million major and minor patient harm events prevented.100 million handoffs using the I-PASS solution.hospitals, the I-PASS Institute and the I-PASS Study Group have seen significant successes over the past decade: To combat these risks, I-PASS has developed methods for improving communication during transitions-and the I-PASS Institute has just celebrated its fifth year using its process. In addition, handoff communication errors can lead to financial costs and reputational harm. The Joint Commission has found that communication mistakes made during patient handoffs are a root cause for more than two-thirds of the most serious errors that befall patients. Patient handoffs present an especially high risk for communication errors. Handoff process marks five years of successįailures in communication frequently prompt medical errors, which make up one of the leading causes of death in the United States, behind heart disease and cancer.
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