New protocols at Walter Reed reduce medical errors

A new procedure for handing off patients during shift changes, developed at Walter Reed National Military Medical Center and several civilian hospitals, has been proved to reduce medical errors, according to a New England Journal of Medicine report.

Facilities using the new protocols, known as I-PASS, saw injuries caused by treatment mistakes drop by 30 percent.

According to the Joint Commission -- the main accrediting body for U.S. hospitals -- roughly 80 percent of serious medical errors involve miscommunication between health providers during the hand-off process.

With the new system, medical personnel use a computer or written record as well as a verbal mnemonic -- I-PASS -- to reinforce proper handoff procedures. I-PASS stands for Illness severity, Patient summary, Action list, Situational awareness and contingency planning and Synthesis by receiver.

According to the researchers, the I-PASS "hand-off bundle" led to a drop in medical errors of 23 percent at the 10 medical centers where it was tested and decline in preventable injures of 30 percent.

The researchers also found that the new handoff procedures took no more time than current protocols.

"The omission of critical information and the transfer of erroneous information during handoffs are common. As resident work hours have been reduced, handoffs between residents have increased in frequency. ... Improving handoffs has become a priority in efforts to improve patient safety," wrote the authors, who included physicians from Walter Reed in Bethesda, Maryland, and the lead center for the study, Boston Children's Hospital.

Providers at Walter Reed Bethesda now use I-PASS in various settings, including adult medicine, surgery and nursing, and are working to integrate it hospitalwide, officials said.

The protocols also are being adopted and taught at the Uniformed Services University of the Health Sciences, the Defense Department's medical school.

"Patients are at the center of everything we do. By quickly adopting I-PASS, we simultaneously bring state-of-the-art health care to our patients and teach the next generation of health care team members what right looks like," said WRNMMC Director Brig. Gen. Jeffrey Clark.

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