A study that looked at a new, structured way of communicating at resident shift changes saw a reduction in medical errors and preventable adverse outcomes.
Residents in Naperville and the greater Chicago area look to physicians for help staying healthy and being restored to health when they are ill. At the same time, the risk that a medical error can be made always exists. This understandably makes many people nervous, especially knowing that Hospital Safety Score, an organization that grades hospitals on how safe they keep their patients from errors, injuries, accidents and infections, indicates up to 440,000 people die due to medical errors each year.
The types of mistakes that can occur range greatly and include things like missed or incorrect diagnoses or giving the wrong medication to a patient. Similarly, the causes or contributing factors to medical mistakes are varied. One study chose to take a look at communication between providers to see what impact it may have on errors.
The I-PASS approach
In the study, residents ending their shifts were instructed to follow a five-step pneumonic to communicate specific information to the residents who were taking over. According to CBS News, this I-PASS system included the following:
- An overview of the illness and how sick the patient was represented the "I" for "illness".
- An overview of the patient's past and current condition represented the "P" for "patient".
- A list of what needed to be done represented the "A" for "action".
- Discussion of alternative actions represented an "S" for "situation."
- Having residents use questions to ensure information was fully understood represented the second "S" for "synthesis".
In addition to this verbal system, physicians were also instructed to leverage electronic charting for documenting all steps.
The study structure
Stanford Medicine reports that the study was led by Boston Children's Hospital and all nine participating hospitals were children's facilities. The concept behind I-PASS was modelled in part on similar communication procedures utilized in other industries. Communication errors may be introduced at various times but this study focused on shift changes only.
According to the New England Journal of Medicine, reductions in both the number of preventable adverse events and medical errors dropped as a result of implementation of the I-PASS system. Prior to the study, preventable adverse effects occurred at a rate of 4.7 out of every 100 patients. That number dropped by 30 percent to 3.3 in the study. Medical errors also dropped to 18.8 out of 100 from a pre-study 24.5, representing a 23 percent decrease. Of specific note was a reduction in the number of mistakes involving patient diagnoses.
Important information for patients
The I-PASS study confirms that more is needed in order to keep patients safe and to prevent mistakes. For this reason, patients themselves must remain proactive and ready to take action when problems arise. Contacting an attorney when a medical error is suspected can give people the help they need to determine what should and can be done.