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  1. Amy Starmer1,
  2. Jennifer O'Toole2,
  3. Nancy Spector3,
  4. Daniel West4,
  5. Theodore Sectish1,
  6. Jeffrey Schnipper5,
  7. Rajendu Srivastava6,
  8. Jenna Goldstein7,
  9. Maria-Lucia Campos1,
  10. Eric Howell8,
  11. Christopher Landrigan1,
  12. SHM I-PASS Study Group1
  1. 1Boston Children's Hospital, United States
  2. 2Cincinnati Children's Medical Center, United States
  3. 3St. Christopher's Hospital for Children, United States
  4. 4UCSF Benioff Children's Hospital, United States
  5. 5Brigham and Women's Hospital, United States
  6. 6Intermountain Healthcare, United States
  7. 7Society for Hospital Medicine, United States
  8. 8Society for Hospital Medicine, United States


Background Handoff miscommunications are a leading source of medical errors. Error rates decreased following implementation of the I-PASS handoff program (a bundled intervention using a structured mnemonic, I-PASS, and other initiatives to sustain implementation) in a pediatric research trial. Whether I-PASS can be implemented in settings outside academic pediatric institutions is unknown.

Objectives To implement I-PASS in a variety of hospitals and medical specialties using a mentored process. (2) To measure the association of I-PASS implementation with handoff quality and provider-reported medical error rates.

Methods We implemented I-PASS in 16 hospitals [community (n=5), academic (n=11)] and multiple specialties [internal medicine (n=7), pediatrics (n=3), other (n=6)]. We paired each site with an external mentorship team of I-PASS experts that conducted a site visit and provided ongoing coaching. Site leads participated in program wide webinars and shared data with participating sites. Validated handoff observation tools and a provider survey assessed handoff quality and rates of adverse events.

Results Implementation was associated with increased inclusion of all 5 I-PASS mnemonic elements for both verbal (14% vs 70%) and written (0% vs 81%) handoffs. Additionally, increases were noted in the frequency of high quality verbal (44% vs 81%) and written (49% vs 73%) patient summaries, verbal (22% vs 82%) and written (44% vs 72%) contingency plans, and verbal receiver syntheses (4% vs 81%). Adverse events decreased by 27%. All changes statistically significant. Improvements were similar across provider types and settings.

Conclusions The I-PASS Handoff program is associated with improved handoff communication in a variety of settings and provider types.

Figure 1

Verbal Handoff Assessments: adherence to all 5 mnemonic elements.

Figure 2

Written Handoff Assessments: adherence to all 5 mnemonic elements.

Figure 3

Verbal Handoff Assessments: quality of patient summaries.

Figure 4

Written Handoff Assessments: quality of patient summaries.

Figure 5

Verbal Handoff Assessments: quality of contigency plans.

Figure 6

Written Handoff Assessments: quality of contigency plans.

Figure 7

Verbal Handoff Assessments: quality of synthesis by receiver.

Figure 8

Provider-reported adverse event rate.

  • Accreditation
  • Anaesthesia
  • Attitudes

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