Multicenter Patient-Safety Study Reduces Medical Error Injuries by 30%

Reported recently in the New England Journal of Medicine (NEJM), 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.

Medical errors in hospitals such as diagnostic delays, preventable surgical complications and medication overdoses are a leading cause of death and injury in the United States. An estimated 80 percent of the most serious medical errors can be linked to communication between clinicians, particularly during patient handoffs. For example, a handoff-related medical error could occur if information about a critical diagnostic test is not communicated correctly between providers at shift change; the result could be a potentially harmful delay in patient care.

“Recent regulations that restrict the working hours of residents have increased the number of handoffs between patient care providers,” says James Bale, MD, site principal investigator for the Primary Children’s/University of Utah study. “The I-PASS technique has reduced medical errors dramatically. It has also increased situation awareness and contingency planning as the care of the patient is transferred from one physician to another at the end of a shift. This is the first multicenter handoff improvement program that has been found to reduce injuries due to medical errors.”

A multicenter team designed I-PASS with the goal of improving patient safety and reducing or eliminating the most common source of medical errors through improved provider-to-provider communication. I-PASS 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 

In the NEJM paper, Landrigan, Starmer and their colleagues report on the results of implementing I-PASS through the pediatric residency programs of nine hospitals:

• Primary Children’s Hospital, University of Utah 

• Benioff Children’s Hospital, University of California San Francisco

• Cincinnati Children’s Hospital Medical Center, University of Cincinnati

• Doernbecher Children’s Hospital, Oregon Health Sciences University

• Hospital for Sick Children, University of Toronto

• Lucile Packard Children’s Hospital, Stanford University

• St. Louis Children’s Hospital, Washington University St. Louis

• St. Christopher’s Hospital for Children, Drexel University

• Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences

“These are all outstanding children’s hospitals, who have worked hard at preventing errors in the past,” says Dr. Bale. “This study shows we can always find ways to improve.”

At each participating hospital, patient handoffs by residents were monitored and assessed 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. 

Bale points out that while the I-PASS bundle has been focused thus far on inpatient pediatric care, the principles are applicable to care in any hospital inpatient setting. And while not documented in the study, he believes that the safety improvements supported by I-PASS adoption could lead to substantial reductions in medical error-related healthcare costs. 

The Forum on Health Care Innovation, a collaboration between Harvard Business School (HBS) and Harvard Medical School (HMS), have named I-PASS one of four finalists in the Health Acceleration Challenge, which focuses on taking compelling, already-implemented healthcare solutions and helping them to grow and increase their impact through powerful networking and funding opportunities.  I-PASS emerged as a finalist from a group of nearly 500 applicants from 29 countries and 43 states.

To learn more, read the NEJM journal article online:
Changes in Medical Errors after Implementation of a Handoff Program​