@article {Starmer1009, author = {Amy Starmer and Jennifer O{\textquoteright}Toole and Nancy Spector and Daniel West and Theodore Sectish and Jeffrey Schnipper and Rajendu Srivastava and Jenna Goldstein and Maria-Lucia Campos and Eric Howell and Christopher Landrigan and SHM I-PASS Study Group}, title = {MENTORED IMPLEMENTATION OF THE I-PASS HANDOFF PROGRAM IN DIVERSE CLINICAL ENVIRONMENTS}, volume = {25}, number = {12}, pages = {1009--1010}, year = {2016}, doi = {10.1136/bmjqs-2016-IHIabstracts.23}, publisher = {BMJ Publishing Group Ltd}, abstract = {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.}, issn = {2044-5415}, URL = {https://qualitysafety.bmj.com/content/25/12/1009}, eprint = {https://qualitysafety.bmj.com/content/25/12/1009.full.pdf}, journal = {BMJ Quality \& Safety} }