Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study

the I-PASS SHM Mentored Implementation Study Group

Research output: Contribution to journalArticlepeer-review


Background: Handoff miscommunications are a leading source of medical errors. Harmful medical errors decreased in pediatric academic hospitals following implementation of the I-PASS handoff improvement program. However, implementation across specialties has not been assessed. Objective: To determine if I-PASS implementation across diverse settings would be associated with improvements in patient safety and communication. Design: Prospective Type 2 Hybrid effectiveness implementation study. Settings and Participants: Residents from diverse specialties across 32 hospitals (12 community, 20 academic). Intervention: External teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews. Main Outcome and Measures: Systematic surveillance surveys assessed rates of resident-reported adverse events. Validated direct observation tools measured verbal and written handoff quality. Results: 2735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, 3 other) participated. 1942 error surveillance reports were collected. Major and minor handoff-related reported adverse events decreased 47% following implementation, from 1.7 to 0.9 major events/person-year (p <.05) and 17.5 to 9.3 minor events/person-year (p <.001). Implementation was associated with increased inclusion of all five key handoff data elements in verbal (20% vs. 66%, p <.001, n = 4812) and written (10% vs. 74%, p <.001, n = 1787) handoffs, as well as increased frequency of handoffs with high quality verbal (39% vs. 81% p <.001) and written (29% vs. 78%, p <.001) patient summaries, verbal (29% vs. 78%, p <.001) and written (24% vs. 73%, p <.001) contingency plans, and verbal receiver syntheses (31% vs. 83%, p <.001). Improvement was similar across provider types (adult vs. pediatric) and settings (community vs. academic).

Original languageEnglish (US)
Pages (from-to)5-14
Number of pages10
JournalJournal of hospital medicine
Issue number1
StatePublished - Jan 2023

ASJC Scopus subject areas

  • Internal Medicine
  • Leadership and Management
  • Fundamentals and skills
  • Health Policy
  • Care Planning
  • Assessment and Diagnosis


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