title: Development, implementation and evaluation of a patient handoff tool to improve safety in orthopaedic surgery.
abstract: OBJECTIVE
  To develop, implement and test the effect of a handoff tool for orthopaedic trauma residents that reduces adverse events associated with the omission of critical information and the transfer of erroneous information.
  
  
  METHODS
  Components of this project included a literature review, resident surveys and observations, checklist development and refinement, implementation and evaluation of impact on adverse events through a chart review of a prospective cohort compared with a historical control group.
  
  
  METHODS
  Large teaching hospital.
  
  
  METHODS
  Findings of a literature review were presented to orthopaedic residents, epidemiologists, orthopaedic surgeons and patient safety experts in face-to-face meetings, during which we developed and refined the contents of a resident handoff tool. The tool was tested in an orthopaedic trauma service and its impact on adverse events was evaluated through a chart review. The handoff tool was developed and refined during the face-to-face meetings and a pilot implementation. Adverse event data were collected on 127 patients (n = 67 baseline period; n = 60 test period).
  
  
  METHODS
  A handoff tool for use by orthopaedic residents.
  
  
  METHODS
  Adverse events in patients handed off by orthopaedic trauma residents.
  
  
  RESULTS
  After controlling for age, gender and comorbidities, testing resulted in fewer events per person (25-27% reduction; P < 0.10).
  
  
  CONCLUSIONS
  Preliminary evidence suggests that our resident handoff tool may contribute to a decrease in adverse events in orthopaedic patients.
authors.affiliation: Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Joel J
authors.initials: JJ
authors.lastname: Gagnier
authors.affiliation: Center for Healthcare Engineering & Patient Safety, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Derosier
authors.affiliation: Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Maratt
authors.affiliation: Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Mark E
authors.initials: ME
authors.lastname: Hake
authors.affiliation: Center for Healthcare Engineering & Patient Safety, University of Michigan, Ann Arbor, MI, USA Department of Industrial & Operations Engineering, University of Michigan, Ann Arbor, MI, USA.
authors.forename: James P
authors.initials: JP
authors.lastname: Bagian
mesh_terms: D000046:Academic Medical Centers / Q000592:standards; D000328:Adult; D000367:Age Factors; D057189:Checklist / Q000592:standards*; D015897:Comorbidity; D005260:Female; D006801:Humans; D007396:Internship and Residency / Q000458:organization & administration* / Q000592:standards; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000592:standards*; D062209:Patient Handoff / Q000592:standards*; D061214:Patient Safety; D011183:Postoperative Complications; D011446:Prospective Studies; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data; D011787:Quality of Health Care / Q000592:standards*; D012307:Risk Factors; D012737:Sex Factors; D014947:Wounds and Injuries / Q000601:surgery
keywords: adverse events; medical errors; orthopaedic trauma resident surgeons; patient handoff; patient safety; safety checklists