20 Patient safety’s hidden threat: variation in process and communication

<h3>Description</h3> Since the release of the Institute of Medicine’s report ”To Err is Human,” miscommunications have remained the leading cause of sentinel events and malpractice claims in healthcare. Addressing these communication issues is key to reducing medical errors and improving patient safety. The aim is to provide a tangible roadmap for a systems-based intervention to address the leading root cause of medical errors: miscommunication. We will review the results of prospective intervention studies of handoff improvement programs (Single center study, 9-center federally funded study, Agency for Healthcare Research and Quality-funded 32 center study), recent results from hospital and system-wide interventions, and recommendations regarding how to successfully adapt handoff programs for specific institutions. Implementation of structured handoff programs results in improved communication reliability and efficiency, 30–50% reductions in preventable harms, and improved experience for providers and patients. Implementation of evidence-based structured communication programs across health systems has the potential to dramatically reduce harmful medical errors and costs.