August Journal: Reducing handoff communication failures and inequities in healthcare

Inspiring studies related to two common sources of adverse events in healthcare – handoff communication failures, and bias and inequities in care – are featured in the August 2024 issue of The Joint Commission Journal on Quality and Patient Safety (JQPS).

• A research team at The University of Texas MD Anderson Cancer Center, Houston, implemented an organization-wide initiative to improve handoffs and implement an evidence-based handoff tool across all inpatient services. The I-PASS tool, designed to standardize handoff documentation, was built into the electronic health record. I-PASS stands for illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis by receiver. Handoff adherence increased from 41.6% in 2019 to 70.5% in 2022, and safety culture scores on handoff favorability rose from 38% in 2018 to 59% in 2022.
• The Patient Equity Wheel, an equity tool and visual aid, was introduced during a two-hour interactive, case-based training across 11 acute care facilities at NYC Health + Hospitals, New York. The Patient Equity Wheel compiles a list of equity categories, including internal, external, and organizational dimensions of equity. A pre- and post-survey assessed knowledge and comfort embedding equity in patient safety event analysis, and measured discomfort or distress during the training. Findings revealed an increase in participant knowledge and level of comfort after training. Post-training feedback noted that tools were being used across the system in various stages of event analysis and improved health equity conversations.

Also featured in the August issue are:

• An Interview with Eduardo Salas, PhD, individual recipient of 2023 John M. Eisenberg Patient Safety and Quality Award
• Screening and Intervention to Prevent Violence Against Health Professionals from Hospitalized Patients: A Pilot Study (Tufts Medical Center, Boston)
• Evaluating Real-World Implementation of INFORM (Improving Nursing Home Care through Feedback on Performance Data): An Improvement Initiative in Canadian Nursing Homes (cohort of 26 nursing homes in British Columbia, Canada)
• Improving Appropriate Use of Peripherally Inserted Central Catheters Through a Statewide Collaborative Hospital Initiative, a Cost-Effectiveness Analysis (The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Michigan)
• Standardizing the Dosage and Timing of Dexamethasone for Postoperative Nausea and Vomiting Prophylaxis at a Safety-Net Hospital System (Case Western Reserve University—MetroHealth System, Cleveland)
• Racial/Ethnic Disparities in Peripartum Pain Assessment and Management (Cedars-Sinai Medical Center, Los Angeles)

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