Interdepartmental transitions of care: a quality improvement project

Abstract

Background: Lack of standardization and communication failures during interdepartmental transitions of care frequently contribute toward sentinel events and medical errors. Local Problem: At a hospital in Montana, lack of standardization and communication failures during interdepartmental handoffs resulted in potential and actual patient safety events. The purpose of this project was to implement a standardized interdepartmental handoff process utilizing a newly developed tool to improve patient safety and nursing staff satisfaction during intradepartmental handoffs. Methods: Incident reports and nurse satisfaction surveys pertaining to interdepartmental patient transfers from the Cardiac Cath Lab to the Intensive Care Unit (ICU) were reviewed pre-and post-implementation of the standardized handoff tool. Intervention: A standardized process utilizing a customized, paper IPASS (Illness severity, Patient summary, Action items, Situation monitoring/Contingency planning, and Synthesis) mnemonic tool was developed and implemented during this project. Results: No handoff incidents were reported and nurse satisfaction pertaining to handoff report between the Cardiac Cath Lab and ICU nurses improved after implementing the IPASS tool. Suboptimal tool usage rates indicate future improvements are required. Conclusions: This project implemented a customized, standardized, handwritten Cardiac Cath Lab-to-ICU handoff tool. Although reported patient safety events declined and nursing satisfaction improved, suboptimal tool use indicates the need for embedding the tool into the electronic medical record.