Title: Implementation of I-PASS handoff tool on a psychiatric inpatient unit
Abstract:
Communication failures during handoff processes present significant risks for medical errors and jeopardize patient safety. The Joint Commission and the Agency for Healthcare Research and Quality's (AHRQ) hospital survey on patient safety culture have consistently identified care transition communication as an area of concern. A mid-sized local psychiatric hospital is facing medication errors in both its young adult and adult units, particularly concerning missed signoffs, along with errors related to nursing and imaging orders. This issue not only reflects poor nursing practices but also raises serious concerns about patient safety. As part of the evidence-based TEAMSTEPPS framework, I-PASS helps nursing staff ensure that essential patient care tasks, like medication administration and pending procedures, are addressed during handoffs. Implementing the I-PASS handoff tool is crucial for improving communication and patient safety on the unit. This structured, checklist-based approach reduces the likelihood of overlooked details, directly addressing the unit's issues with reporting and follow-up on critical care tasks.
Purpose: The purpose of this quality improvement project is to increase communication quality by improving patient handoff practices and decrease medication, nursing and imaging orders errors among nurses in the psychiatric units by implementing an evidence-based, research supported I-PASS standardized handoff tool. Approximately 70 patients are expected to benefit from this project every week.
Methods: During the 15-week implementation period, the nurses will electronically complete the I-PASS handoff report sheet following their verbal handoffs at shift change. Using the "Action List" from the I-PASS acronym, nurses will highlight tasks to be completed by the incoming shift. The project leader will conduct weekly site visits and perform chart audits using a HIPAA-protected data collection tool to document information from the EHR (medical record numbers) and track any missed charting, and record data in REDCap. Data on medication errors, nursing errors, and imaging errors and compliance to I-PASS handoff tool will be collected.
Preliminary Results: Preliminary data shows that compliance with the I-PASS handoff tool has been 20% over the past four weeks. During this period, there have been 19 occurrences involving medication, imaging, or nursing order errors. Of these occurrences, 84.2% were medication-related, primarily due to medications not being properly documented as administered or refused.
Preliminary Conclusions: Preliminary findings suggest that compliance with the handoff tool has been low, likely due to barriers such as lack of EHR integration, nurse forgetfulness, increased workload, and reluctance to use personal cell phones to scan QR codes for survey access. To address these issues, the project leader has implemented several strategies, including placing reminders and informational materials throughout the nursing station, sending emails to highlight compliance rates and medication errors, and motivating staff to enhance their compliance. Additionally, the project leader explored methods to boost adherence with unit manager and CSR and explored using charge phone and unit tablets to access the QR codes. It is expected that compliance will increase to at least 80% in the coming weeks, resulting in a decrease in medication and nursing errors as I-PASS utilization improves.
