Safety effort targeting handoffs cut errors 40%: Boston hospital

Researchers at Boston Children's Hospital have developed a specialized set of protocols they say will improve patient handoffs and reduce the risk of adverse events.

Using a number of bundled interventions, including team-based training and printed handoff instruction sheets, the initiative led to a 40% drop in medical errors during a three-month pilot study, the hospital said in a news release. The program is now being rolled out in 10 pediatric training programs.

The initiative's name, I-PASS, is a mnemonic that stands for "illness severity," "patient summary," "action list for the next team," "situation awareness and contingency plans" and "synthesis and read-back of the information"—all elements that should be included in a successful clinician-to-clinician handoff, the researchers say.

"Despite many efforts, medical errors continue to be very common worldwide and frequently cause harm to patients," Dr. Christopher Landrigan, research and fellowship director of the inpatient pediatric services at Boston Children's Hospital, and the initiative's principal investigator, said in the release. "Reducing handoff errors is a highly promising strategy for improving patient safety. We hope that I-PASS will improve the safety of care across pediatric and adult hospitals once it's widely disseminated."

I-PASS training workshops last three hours and include role-playing exercises. The program also uses the hospital's electronic health-record system to update handoff information in real time and import data quickly, according to the release.