Estimated read time: 2-3 minutes
This archived news story is available only for your personal, non-commercial use. Information in the story may be outdated or superseded by additional information. Reading or replaying the story in its archived form does not constitute a republication of the story.
A study group across the nation is looking at how to reduce medical errors that occur during patient handoffs—when medical staff changes or a patient is moved to a new area in the hospital.
Primary Children’s Hospital and its partner physicians at the University of Utah School of Medicine were among the original nine members of the pediatric I-PASS Study Group, which began gathering data on this issue in 2011. The I-PASS Study Group now includes more than 50 pediatric and adult hospitals nationwide. In 2015, the I-PASS Handoff program was implemented in the Shock/Trauma ICU at Intermountain Medical Center.
The Study Group developed a mnemonic system called I-PASS, which focuses on better communication as the key to better patient care. In addition to teaching the mnemonic, the I-PASS system includes training, developing a checklist, and using more written communication during handoffs.
I-PASS ensured that handoffs were following the same steps every time using the I-PASS acronym. The steps are as follows:
- Illness severity
- Patient summary
- Action list
- Situational awareness and contingency planning
- Synthesis by receiver
Care providers enrolled in the Study Group have focused on the five steps to provide adequate oral and written communication to the next caregiver so there would not be a change in the patient’s treatment plan or any missed steps.
The results of the study showed that the steps were instrumental in improving patient safety and care.
“Standardized handoffs using the I-PASS methodology at Intermountain Medical Center have resulted in improved patient safety without a major effect on efficiency,” said Scott Stevens, MD, director of the transitional year residency program and vice-chair of the Department of Medicine at Intermountain Medical Center.
“Since it was first implemented in our Shock/Trauma ICU, it resulted in a 23 percent reduction in medical errors, a 30 percent reduction in preventable adverse events, and a 21 percent reduction in near-misses—while increasing the time per handoff only minimally, from 2.4 minutes to 2.5 minutes.”
The I-PASS Study Group recently received the 2016 John M. Eisenberg Award for Innovation in Patient Safety and Quality. Raj Srivastava, MD, AVP of Research for Intermountain Healthcare, who was one of six members of the national I-PASS Executive Council, accepted the award for his leadership role in the study. I-PASS has now expanded to include additional hospitals for both pediatric and adult patients as well as expanded to include family-centered rounding.
For more information about the initial I-PASS study results, visit The New England Journal of Medicine.
