TY - JOUR T1 - OSF Saint Francis Medical Center and University of Illinois College of Medicine, Peoria, IL<br/>Rates of Medical Errors and Adverse Events in a Medical ICU Following Implementation of a Standardized Computerized Handoff System JF - Ochsner Journal JO - Ochsner J SP - 38 LP - 39 VL - 16 IS - Spec AIAMC Iss AU - Crystal Davis-Coan AU - Kristin Crawford AU - Teresa Lynch AU - Rachael Davis AU - Tim Miller AU - Thomas J Santoro Y1 - 2016/03/20 UR - http://www.ochsnerjournal.org/content/16/Spec_AIAMC_Iss/38.abstract N2 - Background: The current process in the adult ICU does not include a controlled environment or a consistent process for delivering handoffs or standardized time. This project evaluated the effectiveness of and staff satisfaction with resident handoffs at baseline and then performed a reevaluation after the I-PASS handoff system was integrated with Epic in the OSF Saint Francis Medical Center (SFMC) adult ICU.Methods: We provided a controlled and quiet environment for handoffs, an integrated handoff tool (I-PASS plus Epic), and a robust educational bundle with simulation/role playing, didactics, and small group work. There is a monthly rotation of residents in the adult ICU. We observed handoffs, completed the intervention education, and observed handoffs again (verbally and electronically). The intervention consisted of a 3–4 hour training seminar consisting of a standardized didactic component, sample videos of appropriate and inappropriate handoffs, and interactive simulation training on proper handoffs and event reporting, followed by a debriefing period. Staff and providers completed a daily nursing or resident survey for unreported events, good catches, and near misses. These survey responses were compared to the electronic event reporting system for transparency.Results: We have data for discussion but lack the depth needed to show significance in the intervention month to month. No significant change in the depth of handoff was seen although we found more transparency of the handoff process in the adult ICU.Conclusions: We brought awareness and increased communication about failure points in the process, and this project brought strong leadership commitment to the handoff. Adding good catch to the resident survey was a quick win so the focus was not negative. Standardizing the monthly calendar in advance in terms of timing of education and observations requires more work.View this table:FINAL WORK PLAN – OSF Saint Francis Medical Center and University of Illinois College of Medicine ER -