By Leslie A. Hoffman, RN, PhD
Professor Emeritus,
Nursing and Clinical & Translational Science,
University of Pittsburgh

Dr. Hoffman reports no financial relationships relevant to this field of study.

This article originally appeared in the February 2015 issue of Critical Care AlertIt was edited by Betty Tran, MD, MS, and peer reviewed by William Thompson, MD. Dr. Tran is Assistant Professor of Medicine, Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, and Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Tran and Thompson report no financial relationships relevant to this field of study.

SYNOPSIS: Implementation of a quality improvement project focused on handoffs reduced medical errors by 23% and preventable adverse events by 30%.

SOURCE: Starmer AJ, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med 2014;371:1803-1812.

Numerous studies have tested strategies to improve handoff communication. Most were conducted in a single center and, therefore, the ability to generalize findings remains unclear. The goal of this study was to test the ability of a resident-handoff improvement program to reduce error rates when implemented as a multicenter approach. The nine selected pediatric residency programs ranged in size from 36 to 182 residents and were located in the United States and Canada. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Impact of the program was measured for 6 months pre- and 6 months post-intervention by comparing the number of medical errors, preventable adverse events and miscommunications, as well as resident workflow. Error rates were measured through active surveillance. Handoffs were assessed using printed documents and audio recordings. Workflow was assessed through time-motion observations. In 10,740 patient admissions, the medical error rate decreased by 23% pre- to post-intervention (24.5 vs 18.8 per 100 admissions, < 0.001); preventable adverse events decreased by 30% (4.7 vs 3.3 events per 100 admissions, P < 0.001). There was no change in non-preventable adverse events (3.0 vs 2.8 events per 100 admissions, P = 0.79). Institution-level analyses showed significant error reduction at six of nine sites. Across all sites, increases were observed in the inclusion of key elements during handoffs (nine written, five oral elements; P < 0.001). There was no change pre- to post-intervention in duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P= 0.55) or in resident workflow, including patient–family contact and computer time. Length of stay, medical complexity and patient age did not differ between the pre- and post-intervention period.


The intervention developed for this study, termed the I-PASS Handoff Bundle, included seven elements: the I-PASS mnemonic (I = Illness Severity, P = Patient Summary, A = Action Items, S = Situation Awareness and Contingency Plans, S = Synthesis Restatement by Receiver), a 2-hour workshop to teach communication skills and handoff techniques, a 1-hour role-playing and simulation session to practice skills from the workshop, a computer module to allow for independent learning, a faculty development program, tools to provide feedback to residents, and a process and culture change campaign that included a logo, posters, and materials to promote program adoption. All components are available at no cost through the website (

Measurement was rigorous, including review of medical records, orders, and formal incident reports on study units by a research nurse. Reports were solicited from nursing staff on study units, and daily medical error reports from residents. Two physician investigators, unaware of the time records were collected, classified incidents as preventable or non-preventable. Time and motion data were also collected to determine the time residents spent in various activities. Findings indicated a significant error reduction without an increase in time required to conduct handoffs or a decrease in direct contact time with patients.

 A characteristic of this study, which can be viewed positively and negatively, relates to the comprehensive nature of the intervention and extent of time and institutional commitment required for its implementation. This suggests that handoff communication can be positively influenced, but to achieve this goal, there must be a major effort, including education, practice, availability of online and written support materials, and an institutional effort designed to promote culture change. Of note, error rates did not change significantly at three of the nine institutions. Reasons were unclear, given there was significant improvement in written and oral handoff processes at these institutions. This finding highlights the challenges too often encountered when attempting to change behavior — systematic initiatives can be successful but may not be equally so in different institutions that are influenced by different variables.