A recent study conducted across 32 hospitals found that major and minor handoff-related reported adverse events decreased by 47 percent following implementation of the I-PASS method for reducing medical error and patient harm.
I-PASS is a handoff program that seeks to decrease medical errors and preventable patient harm. The I-PASS acronym stands for illness severity, patient information, action list, situational awareness and contingency plans, and synthesis by receiver.
The purpose of the study, published in the Journal of Hospital Medicine, was to examine how handoff miscommunications, the leading source of medical errors, could be decreased across specialties with the implementation of the I-PASS handoff improvement program. The paper reported that 2,735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, and three other) participated in the study. External teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews.
The findings of the study, published on behalf of the 92-member study group, including Chris Landrigan, M.D., M.P.H., co-founder of the I-PASS Patient Safety Institute and chief of General Pediatrics at Boston Children’s Hospital, highlighted the efficacy of implementing seamless care transitions across adult and pediatric specialties to aid in the reduction of patient harm. For more than a decade, the I-PASS handoff program has been associated with significantly reduced miscommunications, medical errors, and injuries due to medical errors, according to the I-PASS Patient Safety Institute. Founded by clinicians in 2016, the I-PASS Institute leverages expert mentorship paired with technology and digital tools to scale the I-PASS methodology.
“The transfer of patient information between healthcare providers is a known point of vulnerability which can lead to communication failures that result in patient harm and medical malpractice cases,” Landrigan said in a statement. “By implementing evidence-based, standardized handoff communication tools designed to address and reduce knowledge gaps among providers, healthcare organizations are able to overcome organizational barriers and aid in behavior change to help reduce errors and costs associated with malpractice claims. The data shows that implementation of the I-PASS handoff communication tools can result in significant improvements that benefit patients and health systems.”
Previous studies have shown that communication failures are a contributing cause in two out of every three sentinel events, which are the most serious adverse events in hospitals. Communication breakdowns can occur across multiple points in the care journey of a patient. Failure to clearly communicate contingency plans, patient diagnosis, and severity of illness have been found to be some of the most frequent sources of communication failures.
“The findings of our research provide substantial evidence that existing policies should evolve to strongly incentivize the adoption of high-quality, multifaceted handoff programs to further advance patient safety,” said Amy Starmer, M.D., M.P.H., associate medical director of quality at Boston Children’s Hospital in the Department of Pediatrics and co-founder of the I-PASS Patient Safety Institute, in a statement. “Annually, thousands of patients are impacted by adverse events related to communication failures that may have been avoided with proper handoffs. By implementing a standardized process like I-PASS, clinicians can share consistent and highly reliable clinical information using an efficient structure that ensures providers have accurate and critical patient information.”
Landrigan is an equity holder, serves on the board of directors, and is a scientific advisor for the I-PASS Patient Safety Institute. He receives compensation for the scientific advisor role. Boston Children’s Hospital is also an equity holder in I-PASS. Starmer is a co-founder, equity holder, and has received compensation for consulting with the I-PASS Patient Safety Institute.
