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Let’s Talk About It: System Reduces Medical Errors in Patient Hand-Offs

BOSTON – Injuries due to medical errors were reduced 30% in a multicenter study focusing on improvements in verbal and written communication between hospital staff during patient handoffs, according to a recent report.

For the study, researchers developed I-Pass, an original system of bundled communication and training tools for handoff of patient care between providers and found that it significantly increase patient safety without excess burden on existing clinical workflows. The study appeared recently in the New England Journal of Medicine.

According to the article, about 80% of the most serious medical errors can be linked to communication between clinicians, particularly during patient handoffs.

"This is the first multicenter handoff improvement program that has been found to reduce injuries due to medical errors," said the study's principal investigator and senior author, Christopher Landrigan, MD, MPH, of Boston Children's Division of General Pediatrics

He and fellow researchers from multiple medical centers designed I-PASS to:

  • standardize communication and handoff training
  • organize a verbal handoff process around the verbal mnemonic "I-PASS" (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver)
  • computerize handoff tools to share patient information between providers using a standardized structure
  • engage supervising attending physicians to observe and oversee handoff communications

The project also sought to promote the adoption of I-PASS as part of institutional process and culture.

"We recognized that it would take a great deal of work to make the handoff program a sustainable system and encourage its adoption across hospitals," explained lead author Amy Starmer, MD, MPH. "We partnered with experts in research, curriculum development and administration, as well as local faculty and executives at the nine centers to develop a comprehensive and multi-faceted handoff and communication program. Now the new I-PASS program works seamlessly with existing tools and is part of each institution's culture."

At each participating hospital, patient handoffs by medical residents were monitored and assessed for a 6-month pre-intervention period. Residents then were trained on I-PASS handoff processes and informed of the requirements of using the system. The monitoring and assessment continued for six months post-intervention.

Active surveillance was used to measure error rates, and printed handoff documents and audio recordings of the process were evaluated. Workflow was assessed through time-motion observations.

Across all medical centers after the introduction of I-PASS, with 10,740 patient admissions, the rate of medical errors decreased by 23% — from 24.5 to 18.8 errors per 100 admissions. At the same time, preventable adverse events decreased by 30% — from 4.7 to 3.3 errors per 100 admissions. The rate of non-preventable adverse events, however, did not change significantly — 3.0 and 2.8 events per 100 admissions.

“Site-level analyses showed significant error reductions at six of nine sites,” according to the authors. At the same time, they report, “No significant changes were documented from the pre-intervention period to the post-intervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively) or in resident workflow, including patient-family contact and computer time.”

In addition, medical residents' verbal and written communications at every center significantly improved as did residents' satisfaction with the quality of their patient handoffs, according to a post-study survey.

The authors suggest that, while the I-PASS bundle was tested with inpatient pediatric care, it could work in any hospital treatment setting – with the potential of lowering costs related to medical errors.

Hospitals wanting a copy of the curriculum can get it at no cost online at