Hand-off bundle implementation associated with decreased medical errors and preventable adverse events on an academic family medicine in-patient unit: A pre-post study


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Abstract

To determine the impact of the implementation of a hand-off bundle on medical errors at an inpatient unit of an academic community teaching hospital. Our secondary objective was to determine the research utility of the use of an all-electronic data collection system for medical errors.A retrospective review was conducted of 1290 admissions 6 months before and after implementation of an improved computerized hand-off tool and training bundle. The study took place at an academic community teaching hospital on a Family Medicine inpatient service caring for patients of all ages. The comparison focused on preventable and non-preventable adverse events.A significant decrease in medical errors was noted. Medical error rate dropped from 6.0 (95% CI, 4.2–8.3) to 2.2 (95% CI, 1.2–3.7) per 100 admissions (P < .001). Preventable medical errors dropped from 0.65 (95% CI, 0.18–1.67) to 0.15 (95% CI, 0.03–0.82) per 100 admissions (P = .194). Non-intercepted potential adverse events dropped from 1.30 (95% CI, 0.56–2.57) to 0.44 (95% CI, 0.09–1.30) per 100 admissions (P = .131). Intercepted potential adverse events dropped from 0.98 (95% CI 0.36–2.13) to 0.74 (95% CI 0.24–1.7) per 100 admissions (P = .766) and errors with little potential for harm dropped from 2.77 (95% CI 1.61–4.43) to 0.74 (95% CI 0.24–1.7) per 100 admissions (P = .009).Implementation of a standardized hand-off bundle was associated with a reduction in medical errors despite a low overall event rate. Further studies are warranted to determine the generalizability of this finding, to examine the overall epidemiology of medical errors and the reporting of such events within general medical teaching units.

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