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Jennifer Everhart, MD

  • Jennifer L Everhart

Work and Education

Professional Education

Chicago Medical School, North Chicago, IL, 2005

Residency

Children's Hospital of Orange County, Orange, CA, 2009

Board Certifications

Pediatrics, American Board of Pediatrics

Services

Pediatrics

All Publications

Changes in Medical Errors after Implementation of a Handoff Program NEW ENGLAND JOURNAL OF MEDICINE Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., NOBLE, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., Bismilla, Z., Coffey, M., Mahant, S., Blankenburg, R. L., Destino, L. A., EVERHART, J. L., Patel, S. J., Bale, J. F., Spackman, J. B., Stevenson, A. T., Calaman, S., Cole, F. S., Balmer, D. F., Hepps, J. H., Lopreiato, J. O., Yu, C. E., Sectish, T. C., Landrigan, C. P. 2014; 371 (19): 1803-1812
Changes in medical errors after implementation of a handoff program. New England journal of medicine Starmer, A. J., Spector, N. D., Srivastava, R., West, D. C., Rosenbluth, G., Allen, A. D., Noble, E. L., Tse, L. L., Dalal, A. K., Keohane, C. A., Lipsitz, S. R., Rothschild, J. M., Wien, M. F., Yoon, C. S., Zigmont, K. R., Wilson, K. M., O'Toole, J. K., Solan, L. G., Aylor, M., Bismilla, Z., Coffey, M., Mahant, S., Blankenburg, R. L., Destino, L. A., Everhart, J. L., Patel, S. J., Bale, J. F., Spackman, J. B., Stevenson, A. T., Calaman, S., Cole, F. S., Balmer, D. F., Hepps, J. H., Lopreiato, J. O., Yu, C. E., Sectish, T. C., Landrigan, C. P. 2014; 371 (19): 1803-1812

Abstract

Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking.We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events.In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time.Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).

View details for DOI 10.1056/NEJMsa1405556

View details for PubMedID 25372088

I-PASS Handoff Curriculum: Core Resident Workshop MedEdPORTAL Spector N, Starner A, Allen A, Bale J, Bismilla Z, Calaman S, Coffey M, Cole F, Destino L, Everhart J, Hepps J, Kahana M, Lopreiato J, McGregor R, O'Toole J, Patel S, Rosenbluth G, Srivastava R, Stevenson A, Tse L, Yu C, West D, Sectish T, Landrigan C 2013
I-PASS Handoff Curriculum: Campaign Toolkit MedEdPORTAL Spector N, Rosenbluth G, Patel S, Destino L, OToole J, Everhart J, Stevenson A, Yu C, Calaman S, Allen A, Starmer A, Landrigan C, Sectish T 2013
I-PASS, a Mnemonic to Standardize Verbal Handoffs PEDIATRICS Starmer, A. J., Spector, N. D., Srivastava, R., Allen, A. D., Landrigan, C. P., Sectish, T. C. 2012; 129 (2): 201-204

View details for DOI 10.1542/peds.2011-2966

View details for Web of Science ID 000300395100040

View details for PubMedID 22232313