According to an Aug. 22 press release, studies related to two common sources of adverse events in healthcare, handoff communication failures, and bias and inequities in care, are featured in the August 2024 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS).
Handoff communication failures
The press release says that “Communication failures are among the most frequent causes of harmful medical errors. An estimated 67% of communication errors relate to handoffs (the time when patient care responsibility transitions from one provider to another).”
Further, “A research team at The University of Texas MD Anderson Cancer Center, Houston, implemented an organization-wide initiative to improve handoffs and implement an evidence-based handoff tool across all inpatient services. I-PASS stands for illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis by receiver. The I-PASS tool, designed to standardize handoff documentation, was built into the electronic health record (EHR).”
The study found that, according to the press release, handoff adherence increased from 41.6% in 2019 to 70.5% in 2022, and safety culture scores on handoff favorability rose from 38% in 2018 to 59% in 2022.
Bias and inequities in care
The press release also states that adverse events occur in almost one out of every four hospital admissions, a quarter of which are preventable.
“A quality improvement initiative introduced equity tools during a two-hour interactive, case-based training across 11 acute care facilities at NYC Health + Hospitals, New York,” the release adds. “The training featured a visual aid, referred to as the Patient Equity Wheel, which facilitated comprehensive and robust health equity discussions. The Patient Equity Wheel compiles a list of equity categories, including internal, external, and organizational dimensions of equity.”
A pre- and post-survey evaluated knowledge and comfort inserting equity in patient safety event analysis, and measured discomfort or distress during the training. The findings discovered “an increase in participant knowledge and level of comfort after training.” Post-training feedback saw that tools were being used across the system in various stages of event analysis and improved health equity discussions.
