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Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow
  1. Amy J Starmer1,
  2. Kumiko O Schnock2,
  3. Aimee Lyons3,4,
  4. Rebecca S Hehn5,
  5. Dionne A Graham5,
  6. Carol Keohane2,6,
  7. Christopher P Landrigan1,2,7
  1. 1Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
  2. 2Center for Patient Safety Research and Practice, Division of General Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
  3. 3Department of Critical Care, Boston Children’s Hospital, Boston, Massachusetts, USA
  4. 4Franciscan Children’s, Brighton, Massachusetts, USA
  5. 5Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, Massachusetts, USA
  6. 6CRICO/Risk Management Foundation of the Harvard Medical Institutions, Boston, Massachusetts, USA
  7. 7Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Amy J Starmer, Boston Children's Hospital, 300 Longwood Ave, Hu 262, Boston 02115, MA, USA; amy.starmer{at}


Background and objective Handoff communication errors are a leading source of sentinel events. We sought to determine the impact of a handoff improvement programme for nurses.

Methods We conducted a prospective pre-post intervention study on a paediatric intensive care unit in 2011–2012. The I-PASS Nursing Handoff Bundle intervention consisted of educational training, verbal handoff I-PASS mnemonic implementation, and visual materials to provide reinforcement and sustainability. We developed handoff direct observation and time motion workflow assessment tools to measure: (1) quality of the verbal handoff, including interruption frequency and presence of key handoff data elements; and (2) duration of handoff and other workflow activities.

Results I-PASS implementation was associated with improvements in verbal handoff communications, including inclusion of illness severity assessment (37% preintervention vs 67% postintervention, p=0.001), patient summary (81% vs 95%, p=0.05), to do list (35% vs 100%, p<0.001) and an opportunity for the receiving nurse to ask questions (34% vs 73%, p<0.001). Overall, 13/21 (62%) of verbal handoff data elements were more likely to be present following implementation whereas no data elements were less likely present. Implementation was associated with a decrease in interruption frequency pre versus post intervention (67% vs 40% of handoffs with interruptions, p=0.005) without a change in the median handoff duration (18.8 min vs 19.9 min, p=0.48) or changes in time spent in direct or indirect patient care activities.

Conclusions Implementation of the I-PASS Nursing Handoff Bundle was associated with widespread improvements in the verbal handoff process without a negative impact on nursing workflow. Implementation of I-PASS for nurses may therefore have the potential to significantly reduce medical errors and improve patient safety.

  • Hand-off
  • Communication
  • Nurses
  • Patient safety

Statistics from


  • Contributors AJS and CL designed the study. KOS collected the data. RH and DAG performed the statistical analyses. AJS wrote the original draft of the manuscript. AJS, KOS, AL, RH, DAG, CK and CL were involved in interpreting the findings and editing the manuscript. AJS is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

  • Competing interests AJS reported receiving honoraria and travel reimbursement from multiple academic and professional organisations for delivering lectures on handoffs and patient safety. She has consulted with and holds equity in the I-PASS Institute, which seeks to train institutions in best handoff practices and aid in their implementation. CL likewise has consulted with and holds equity in the I-PASS Institute. In addition, he has served as a paid consultant to Virgin Pulse to help develop a Sleep and Health Program. He is supported in part by the Children’s Hospital Association for his work as an Executive Council member of the Pediatric Research in Inpatient Settings (PRIS) network. He has received monetary awards, honoraria and travel reimbursement from multiple academic and professional organisations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety, and has served as an expert witness in cases regarding patient safety and sleep deprivation. No other authors reported disclosures.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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