Handoff Improvement Program Results in Patient Safety Gains

Implementation of I-PASS – an evidence-based program designed to teach, evaluate and improve patient handoffs between providers and settings – has led to substantial gains in patient safety and can be applied to a variety of disciplines and types of handoffs, according to new research partially funded by AHRQ. Researchers and clinicians developed I-PASS to reduce medical errors and adverse events associated with handoff communication failures. When initially implemented in nine pediatric hospital units, I-PASS was associated with a 30 percent reduction in injuries and significant improvements in handoff processes. AHRQ subsequently funded the I-PASS Mentored Implementation Program to adapt and implement I-PASS to other clinical settings and types of providers across 35 hospitals. Sixteen hospitals that have completed implementation showed significant improvements in the quality of handoffs, as well as significant reductions in handoff-related adverse events. Implementation is underway at the other 19 hospitals. Authors of the new study, published in The Joint Commission Journal on Quality and Patient Safety, concluded that widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond. Access the study abstract. The research follows the development of an intervention on “warm handoffs” that will become part of AHRQ’s Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families. Warm handoffs are those that occur transparently in the presence of patients and family members.

2017 Jul;43(7):319-329. doi: 10.1016/j.jcjq.2017.04.001. Epub 2017 Jun 1.

Integrating Research, Quality Improvement, and Medical Education for Better Handoffs and Safer Care: Disseminating, Adapting, and Implementing the I-PASS Program.

Starmer AJ, Spector ND, West DC, Srivastava R, Sectish TC, Landrigan CP; I-PASS Study Group.

Collaborators (186)

Abstract

BACKGROUND:

In 2009 the I-PASS Study Group was formed by patient safety, medical education, health services research, and clinical experts from multiple institutions in the United States and Canada. When the I-PASS Handoff Program, which was developed by the I-PASS Study Group, was implemented in nine hospitals, it was associated with a 30% reduction in injuries due to medical errors and significant improvements in handoff processes, without any adverse effects on provider work flow.

METHODS:

To effectively disseminate and adapt I-PASS for use across specialties and disciplines, a series of federally and privately funded dissemination and implementation projects were carried out following the publication of the initial study. The results of these efforts have informed ongoing initiatives intended to continue adapting and scaling the program.

RESULTS:

As of this writing, I-PASS Study Group members have directly worked with more than 50 hospitals to facilitate implementation of I-PASS. To further disseminate I-PASS, Study Group members delivered hundreds of academic presentations, including plenaries at scientific meetings, workshops, and institutional Grand Rounds. Some 3,563 individuals, representing more than 500 institutions in the 50 states in the United States, the District of Columbia, Puerto Rico, and 57 other countries, have requested access to I-PASS materials. Most recently, the I-PASSSM Patient Safety Institute has developed a virtual immersion training platform, mobile handoff observational tools, and processes to facilitate further spread of I-PASS.

CONCLUSION:

Implementation of I-PASS has been associated with substantial improvements in patient safety and can be applied to a variety of disciplines and types of patient handoffs. Widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond.