I PASS Standardizing patient handoffs to reduce medical errors

April 29, 2012

Boston, Mass. - A new patient safety and medical education initiative, standardizing and improving how patient care is “handed off” during hospital shift changes, can reduce medical errors by as much as 40 percent, report physicians at the Pediatric Academic Societies annual meeting in Boston. The initiative, called I-PASS, was developed at Boston Children’s Hospital and is currently being implemented and tested in 10 pediatric training programs across North America, including the residency training program at Boston Children’s.

A pilot study, led by Amy Starmer, MD, MPH, of the Division of General Pediatrics at Boston Children’s Hospital, developed and tested a novel set ofpatient handoff procedures that served as the foundation for I-PASS, and was the first to test such measures on a large scale. Findings of the study, and details on the development of I-PASS, were presented today in a plenary session by I-PASS principal investigatorChristopher P. Landrigan, MD, MPH, Research and Fellowship Director of the Inpatient Pediatrics Service at Boston Children’s Hospital, and Theodore Sectish, MD, Program Director of the hospital’s pediatric residency program.  

The I-PASS curriculum, which will now be shared nationally and internationally, seeks to improve communication during residents’ shift changes, ensuring that incoming doctors are thoroughly and accurately briefed on each patient’s medical history, status and treatment plan. National data suggest that up to 70 percent of sentinel events – the most serious errors in hospitals – stem at least in part from miscommunications, including those during handoffs.

“Despite many efforts, medical errors continue to be very common worldwide, and frequently cause harm to patients,” says Landrigan. “Reducing handoff errors is a highly promising strategy for improving patient safety. We hope that I-PASS will improve the safety of care across pediatric and adult hospitals once it’s widely disseminated.”

Developed in collaboration with educators, hospitalists and health services researchers across the U.S. and in Canada, I-PASS has several major elements bundled into a single intervention: Team training for clinicians in communication and teamwork skills (using the TeamSTEPPSTM program developed by the Department of Defense and the Agency for Healthcare Research and Quality); an easy-to-remember mnemonic to ensure that key information is imparted in each handoff (I– Illness severity; P – Patient summary; A – Action list for the next team;S - Situation awareness and contingency plans; S – Synthesis and “read-back” of the information);creation of a printed handoff document that can be integrated into the patient’s electronic medical record; and direct, structured observation of handoffs by senior physicians, with feedback.

  • The pilot study compared the three months before and after introduction of the handoff program on which I-PASS was eventually based. Its key findings:
  • A 40 percent reduction in medical errors after implementation (from 32 percent of admissions to 19 percent).  
  • Doctors spent more time with patients (225 minutes per 24-hour period, versus 122 minutes before implementation of the handoff program) and less time at the computer (370 vs. 408 minutes per 24 hours).
  • Handoffs were about twice as likely to occur in a private or quiet location.

Printed handoff documents included significantly more information. For example, the number of sign-outs that included a “To-do” list for the patient increased from 29 to 82 percent. Medication lists went from being included 3 percent to 100 percent of the time, largely because the handoff form could pull information directly from the patient’s medical record.

Residents are trained in I-PASS through a 3-hour interactive workshop that includes simulations and role-plays where they give and receive handoffs during different clinical scenarios. Residents and senior physicians also receive continuous refresher training, feedback in real time from attending physicians observing handoffs, and discuss I-PASS “tips of the day” (example: With a shared mental model, team members are "on the same page." Are you thinking what I'm thinking?”).

A major part of the initiative includes integrating the information exchanged during handoff with the hospital’s electronic medical record system. “Previously, residents were retyping a lot of information that wasn’t always updated as things changed,” says Starmer, now at Oregon Health and Science University. “The new tool lets you import information automatically, and standardizes the written documentation.”

A workshop on I-PASS for physicians will be conducted at the Pediatric Academic Societies meeting on Tuesday, May 1, 8:30-11:30 a.m. (Sheraton Boston Hotel, Republic B), when a new I-PASS website (www.ipasshandoffstudy.com)will be launched and the curriculum made available to any hospital. 

The ongoing I-PASS study is funded by the Department of Health and Human Services and the NIH through American Recovery and Reinvestment Act Stimulus funding, and is supported by the Pediatric Research in Inpatient Settings (PRIS) hospital research network, and the Initiative for Innovation in Pediatric Education (IIPE). The pilot study was funded by the Harvard Risk Management Foundation and Boston Children’s Program in Pediatric Safety and Quality.

Rob Graham

Boston Children’s Hospital is home to the world’s largest research enterprise based at a pediatric medical center, where its discoveries have benefited both children and adults since 1869. More than 1,100 scientists, including nine members of the National Academy of Sciences, 11 members of the Institute of Medicine and nine members of the Howard Hughes Medical Institute comprise Boston Children’s research community. Founded as a 20-bed hospital for children, Boston Children’s Hospital today is a 395 bed comprehensive center for pediatric and adolescent health care grounded in the values of excellence in patient care and sensitivity to the complex needs and diversity of children and families. Boston Children’s is also the primary pediatric teaching affiliate of Harvard Medical School. For more information about research and clinical innovation at Boston Children’s, visit: http://vectorblog.org.