This review features a 2017 case study by the Agency for Healthcare Research and Quality (AHRQ) titled Johns Hopkins Children’s Center Uses AHRQ-Funded I-PASS Tool to Boost Patient Safety.
The aforementioned AHRQ case study focused on a shift in operations at the John Hopkins Children’s Center in Baltimore which allowed residents to effectively hand off patients within their care using an inaugural AHRQ supported tool dubbed I-PASS. At the core of this complex instrument was its role as a transition tool for improving communication during the transfer of patients during routine shift rotations. Results gathered from the research linked I-PASS to an overall improvement in communication when handing off patients during routine transfer of care. This was particularly significant in preventing adverse events linked to errors during patient transfer; ultimately improving the quality of care provided while bolstering patient safety.
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The research team at John Hopkins Children’s Center employed quantitative data collection methods through meticulous performance monitoring of the data collected before proceeding with analysis. The facility was among a group of 32 participants which undertook the arduous task of monitoring the overall effectiveness of applying I-PASS within a healthcare facility. Pediatric residents were then monitored after the implementation of the process to assess their adherence its components. The result was an improvement from a 75% to 100% in the rate of compliance with I-PASS standards; credited for improving the handing off of patients from one group to the next during hospital shifts (“Johns Hopkins children’s center uses AHRQ-funded I-PASS tool to boost patient safety,” 2017). Furthermore, the analysis applied in the case study was based on the ability of resident pediatrician to adhere to identified I-PASS components during routine patient’s transfers,
The outcomes of this case study are pertinent in today’s industry’s standards owing to an overall adherence to established protocols within healthcare. Participants from John Hopkins Children’s Center were first matched with participants versed in the inner workings the I-PASS process. Common practice often dictates that such experts make frequent visits to meet residents and provide further coaching on the implementation of a specified tool (“Significant medical errors experienced by 21% of Americans,” 2017). In this case, I-PASS experts were directly responsible for providing coaching each month with the main aim of making certain that communication was enriched during handoffs. It ultimately became a common fixture within the organization owing to the wide range of cumulative benefits stemming from its implementation.
AHRQ’s I-PASS tool implemented by the John Hopkins Children’s Center and its accompanying practices can be applied within my organization. My practice as a family practitioner nurse (FPN) has afforded me the opportunity to be aware of the significance of accuracy and effective communication within the practice. Handoffs characterized by accuracy during transfers are a particularly essential as a way of preventing medical errors which are known for their negative impact in the event they go unnoticed (Wachter & Gupta, 2017). This is crucial in averting instances where poor communication is clearly to blame for errors made by clinical staff while understanding different ways in which efficacious tools can be applied.
The result of applying this new practice would be an improvement in coordination among fellow clinical practitioners during handoff based on the application of pertinent communication tools. Each member will always remain aware of the workplace routine and specific shift rotations and accompanying practices. This will improve synchronization during transfers through the implementation of a standardized framework to be followed by clinical during transfer of patients with different conditions while promoting patient safety.
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