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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 Week “Handoffs – 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 prior.to 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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