Improved Handoff Communication Reduces Medical Error Injuries by 30%

Improved Handoffs

A multicenter study led by researchers from Boston Children’s Hospital shows that the I-PASS bundle improves patient safety and quality of care. Physicians at Primary Children’s Hospital and the University of Utah School of Medicine participated as one of the nine pediatric hospitals in the I-PASS study.

Reported Nov. 6 in the New England Journal of Medicine (NEJM), the study results show that I-PASS—an original system of bundled communication and training tools for handoff of patient care between providers—can greatly increase patient safety without significantly burdening existing clinical workflows.

An estimated 80 percent of the most serious medical errors can be linked to communication deficiencies among clinicians, particularly during patient handoffs. To address these problems, the I-PASS bundle consists of:

  • standardized communication and handoff training
  • a verbal handoff process organized around the verbal mnemonic "I-PASS" (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver)
  • computerized handoff tools to share patient information between providers using an I-PASS structure
  • engagement of supervising attending physicians to observe and oversee handoff communications
  • a campaign promoting the adoption of I-PASS as part of institutional process and culture

James Bale, M.D., Raj Srivastava, M.D., M.P.H., and Adam Stevenson, M.D. co-led the Primary Children’s Hospital/University of Utah School of Medicine team. Leadership within Intermountain’s Institute for Health Care Delivery and Research had additional responsibilities by taking a lead role in the overall governance and conduct of the study.

The researchers monitored patient handoffs by residents at each participating hospital, and assessed them for a six-month pre-intervention period. During the six-month intervention phase, residents were trained on I-PASS handoff processes and required to use the system going forward. An additional six months of monitoring and assessment followed the intervention.

Across the participating centers, the overall rate of medical errors decreased by 23 percent—from 24.5 to 18.8 errors per 100 admissions—after the introduction of I-PASS. Preventable adverse events (injuries due to medical errors) decreased by 30 percent—from 4.7 to 3.3 errors per 100 admissions. The research team's data covered a total of 10,740 patient admissions.

Time-motion analyses of providers' activities showed that implementing I-PASS did not add time to patient handoffs or decrease time spent at patient bedsides or on other tasks. The researchers noted significant improvements in residents' verbal and written communications at every center and a significant increase in residents' satisfaction with the quality of their patient handoffs after I-PASS implementation, according to a post-study survey.

Find the I-PASS curriculum online at For consultation and ongoing support with program implementation for institutions, email