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Patient Safety Tip of the Week

December 20, 2022

Amazing Results from I-PASS Implementation



Handoffs present vulnerabilities that often lead to untoward outcomes and patient safety events and have been one of our most frequent topics over the years. We’ve discussed the various formats that have been used for handoffs and note that many are tailored for specific types of handoff.


We’ve extolled the success of the I-PASS handoff format and culture in many columns. We first described I-PASS 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. But 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 December 2014 What's New in the Patient Safety World column “I-PASS Passes the Test” we discussed the publication of the final results of the I-PASS project (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.


Then, in our November 2019 What's New in the Patient Safety World column “I-PASS Delivers Again” we noted another study demonstrating that implementation of a handoff bundle, modeled on the intervention in the original I-PASS study, was associated with decreased medical errors and preventable adverse events on an academic family medicine inpatient unit (Dewar 2019).


We thought those previous reports on the success of I-PASS were impressive. Well, results of implementation of I-PASS in diverse clinical environments are even more impressive. Starmer et al. (Starmer 2022) recently published results of implementation of I-PASS at a diverse group of 32 adult, pediatric, academic, and community hospitals. They found a 47.1% reduction in the frequency of handoff‐related major adverse events and a 46.9% reduction in handoff‐related, minor harm events after I-PASS implementation. Improvements were similar across provider types (adult vs. pediatric) and settings (community vs. academic).


In addition, there were marked improvements in the completeness and quality of handoff communications. Completeness of verbal handoffs improved from 20 percent prior to implementation to 66 percent after implementation. Completeness of written handoffs improved from 10 percent 74 percent. And there were dramatic improvements in the perception of quality of the handoffs by those on both the giving and receiving ends of the handoffs.


Note that this study was focused on resident physician end‐of‐shift handoffs, with a primary focus on general pediatric and internal medicine units. But we have no reason to think that I-PASS would not be equally successful for residents in specialty programs or attendings such as hospitalists.



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

December 2014            I-PASS Passes the Test

January 6, 2015            Yet Another Handoff: The Intraoperative Handoff

March 2017                 Adding Structure to Multidisciplinary Rounds

August 22, 2017         OR to ICU Handoff Success

October 2017              Joint Commission Sentinel Event Alert on Handoffs

October 30, 2018        Interhospital Transfers

April 9, 2019               Handoffs for Every Occasion

November 2019          I-PASS Delivers Again

August 2020               New Twist on Resident Work Hours and Patient Safety

September 29, 2020    ISHAPED for Nursing Handoffs

May 25, 2021              Yes, Radiologists Have Handoffs, Too

February 2022             Communication Failures and Malpractice

June 7, 2022                SBAR to the Rescue!






I-PASS Study website.



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



Dewar Z, Yurkonis T, Attia M. Hand-off bundle implementation associated with decreased medical errors and preventable adverse events on an academic family medicine in-patient unit: A pre-post study. Medicine 2019; 98(40): e17459, October 2019



Starmer, AJ, Spector, ND, O'Toole, JK, et al. Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. J Hosp Med. 2022; 1- 10 First published: 03 November 2022






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