What’s New in the Patient Safety World

June 2012

I-PASS Results and Resources Now Available



In our February 14, 2012 Patient Safety Tip of the WeekHandoffs – More Than Battle of the Mnemonics” we highlighted a new standardized handoff project “I-PASS” being piloted in a collaborative project led by Boston Children’s Hospital and several pediatric organizations (Starmer 2012). The leaders of the pediatric collaborative recognized that the SBAR format does not work very well for resident-to-resident handoffs, etc. because the situations are much more complex. So, even though adoption of SBAR has been shown to reduce adverse events in hospitals, they looked at other formats. Feedback from residents involved in a pilot of one tool said that a tool/format needed to be short, easy to remember, and not have elements that overlapped each other. They also recognized that it would have to integrate with the increasing use of computerized tools for handoffs and other communication. So they came up with the I-PASS format (and note that even though it sounds like the I PASS the BATON format it is a totally different format):

I: Illness Severity

P: Patient Summary

A: Action List

S: Situation Awareness and Contingency Planning

S: Synthesis by Receiver


The final “S” emphasizes a key feature of all successful communication: it ensures that the message is fully understood by the person receiving the handoff, including asking questions then summarizing the key steps and restating the key actions/to-do steps. The Starmer article includes a nice example of use of the I-PASS format in a clinical handoff. The Starmer article also summarizes some of the key elements that make a mnemonic successful. It needs to be “catchy”, symbolic, parsimonious, utilitarian, and somehow link a visual image to a process or subject. The I-PASS mnemonic certainly accomplishes that.


But make no mistake. This project is much more than just a new format. It also involves extensive team training (based on TeamSTEPPS™), simulation and role playing, direct observation of handoffs with feedback, and generation of a printed handoff document that can be integrated with the electronic medical record.


The I-PASS Study collaborative is now ongoing at 10 pediatric institutions and they have now demonstrated a significant reduction in medical errors after implementation of the program (Boston Children’s Hospital 2012). They found a 40% reduction in medical errors in a before and after study. Amazingly, they also found significant increases in patient contact and reduced computer time after implementation. They also documented numerous improvements in elements of the handoff process.


They have now made available many of the tools used in the program on the I-PASS website. These include materials for training both residents and faculty/attendings, sample simulations and role playing exercises, tools for feedback for direct observation of handoffs, and many other great tools.


Kudos to everyone involved in this project! They have done a great job addressing one of the most problematic interactions we see in medicine. Whether or not you adopt the I-PASS format itself at your institution, you will learn an incredible amount about handoffs and communication from this project.




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






Starmer AJ, Spector ND, Srivastava R, et al. and  the I-PASS Study Group. I-PASS, a Mnemonic to Standardize Verbal Handoffs.

Pediatrics 2012; 129(2): 201 -204




Boston Children’s Hospital. I-PASS: Standardizing patient "handoffs" to reduce medical errors. News Release April 29, 2012




I-PASS Study website.
















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