What’s New in the Patient Safety World

December 2014

I-PASS Passes the Test



Amongst our numerous columns on handoffs/handovers (see the full list of prior columns at the end of today’s column) we’ve especially been fond of the I-PASS handoff program. We first described it in our February 14, 2012 Patient Safety Tip of the WeekHandoffs – More Than Battle of the Mnemonics”, a column that highlighted the need to tailor handoff formats to the specific tasks at hand. I-PASS came about because existing formats were not optimal for resident-to-resident handoffs. Then in our June 2012 What’s New in the Patient Safety World column “I-PASS Results and Resources Now Available” we noted the release of the very promising preliminary results of the I-PASS project.


Now the final results of the I-PASS project have been published (Starmer 2014). After implementation of I-PASS the rate of medical errors decreased by 23% and the rate of preventable medical errors decreased by 30%. Significantly, there was no increase in the amount of time spent on handoffs and there was no significant change in resident workflow or the amount of resident contact with patients and families.


Specific medical error types reduced in the I-PASS collaborative included diagnostic errors, errors related to medical history or physical examination, multifactorial errors, and errors related to therapies other than medications or procedures. (Errors related to medications, procedures, falls, and nosocomial infections did not change.)


The reduction in medical errors was significant at six of the nine sites participating. Study authors had no explanation for the lack of improvement at three sites, since they also demonstrated improved inclusion of key elements in the handoff process.


Make no mistake, I-PASS is much more than a mnemonic and format for handoffs. It also involves extensive team training (based on TeamSTEPPS™) and resident training modules, simulation and role playing, faculty development resources and tools, direct observation of handoffs with feedback, and generation of a printed handoff document that can be integrated with the electronic medical record.


In our September 9, 2014 Patient Safety Tip of the Week “The Handback” we noted that a recent collaboration among 23 pediatric hospitals (Bigham 2014) demonstrated a significant decrease in handoff-related are failures for multiple different handoff types. I-PASS was a format utilized in that collaboration. The improvement project was guided by evidence-based recommendations regarding handoff intent and content, standardized handoff tools/methods, and clear transition of responsibility. Hospitals tailored handoff elements to locally important handoff types. Examples of the handoff types included shift-to-shift handoffs, emergency department to inpatient handoffs, and perioperative to inpatient handoffs. Handoff-related care failures decreased from 25.8% at baseline to 7.9% in the final intervention period.


Compliance to critical components of the handoff process improved, as did provider satisfaction. Key elements required, regardless of the handoff type, were that active participation by both the sending and receiving teams were required, discrete times

and mechanisms set aside for the receiving team to ask questions, a proscribed script of important handoff elements was available, and a “read back” summary of basic issues and next steps was accessible. One very interesting finding was that even where baseline compliance with individual elements was pretty good at baseline, relatively small incremental improvements in those individual elements collectively led to very good reductions in overall handoff failures.


Details on the format of I-PASS and reasons for its development can be found in our February 14, 2012 Patient Safety Tip of the WeekHandoffs – More Than Battle of the Mnemonics” and June 2012 What’s New in the Patient Safety World column “I-PASS Results and Resources Now Available” as well as in the current article (Starmer 2014) and the I-PASS website.


Though restrictions on hours that residents may work have increased the number and complexity of handoffs/handovers, most of the same issues apply to other physician coverage arrangements. Yes, one resident just finishing a 24-hour shift may have to leave immediately after morning rounds. But a physician in a community or rural hospital who is covering for another physician also has competing requirements for his/her time (eg. office hours, scheduled surgery, etc.). And the same types of interruptions and distractions (phone calls, pages, nurses or colleagues or families requesting information, etc.) apply equally well to morning rounds or the physician cross-coverage handback.


Though neither the I-PASS collaborative nor the previously mentioned pediatric collaborative (Bigham 2014) looked at the impact of the missed handoff issues on patient harm or actual patient outcomes, we would certainly predict that improvement in the handback process would likely prevent many adverse events and outcomes. Both are very good studies and have implications for all healthcare organizations, not just academic ones.




Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:


May 15, 2007              Communication, Hearback and Other Lessons from Aviation

May 22, 2007              More on TeamSTEPPS

August 28, 2007         Lessons Learned from Transportation Accidents

December 11, 2007     Communication…Communication…Communication

February 26, 2008       Nightmares….The Hospital at Night

September 30, 2008     Hot Topic: Handoffs

November 18, 2008     Ticket to Ride: Checklist, Form, or Decision Scorecard?

December 2008            Another Good Paper on Handoffs”.

June 30, 2009               iSoBAR: Australian Clinical Handoffs/Handovers

April 25, 2009             Interruptions, Distractions, Inattention…Oops!

April 13, 2010             Update on Handoffs

July 12, 2011               Psst! Pass it on…How a kid’s game can mold good handoffs

July 19, 2011               Communication Across Professions

November 2011           Restricted Housestaff Work Hours and Patient Handoffs

December 2011            AORN Perioperative Handoff Toolkit

February 14, 2012       Handoffs – More Than Battle of the Mnemonics

March 2012                 More on Perioperative Handoffs

June 2012                    I-PASS Results and Resources Now Available

August 2012               New Joint Commission Tools for Improving Handoffs

August 2012                Review of Postoperative Handoffs

January 29, 2013         A Flurry of Activity on Handoffs

December 10, 2013     Better Handoffs, Better Results

February 11, 2014       Another Perioperative Handoff Tool: SWITCH

March 2014                  The “Reverse” Perioperative Handoff: ICU to OR

September 9, 2014      The Handback






Starmer AJ, Spector ND, Srivastava R, et al. Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med 2014; 371: 1803-1812




Bigham MT, Logsdon TR, Manicone PE, et al. Decreasing Handoff-Related Care Failures in Children’s Hospitals. Pediatrics 2014; 134:2 e572-e579; published ahead of print July 7, 2014,




I-PASS Study website.






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