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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!”
References:
I-PASS Study website.
http://www.ipasshandoffstudy.com/home
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
http://www.nejm.org/doi/full/10.1056/NEJMsa1405556
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
https://insights.ovid.com/crossref?an=00005792-201910040-00080
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
https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.12979
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