MENTORED IMPLEMENTATION OF THE I-PASS HANDOFF PROGRAM IN DIVERSE CLINICAL ENVIRONMENTS. Issue 12 (18th November 2016)

• Record Type: Journal Article
• Authors: Starmer, Amy; O'Toole, Jennifer; Spector, Nancy; West, Daniel; Sectish, Theodore; Schnipper, Jeffrey; Srivastava, Rajendu; Goldstein, Jenna; Campos, Maria-Lucia; Howell, Eric; Landrigan, Christopher
• Is Part Of: BMJ quality & safety. Volume 25:Issue 12(2016)
• Page Start: 1009
• Page End: 1010
• Publication Date: 2016-11-18
• Subjects: Accreditation -- Anaesthesia -- Attitudes; Medical care -- Quality control -- Periodicals; Health facilities -- Risk management -- Periodicals; Medical errors -- Prevention -- Periodicals; 362.106805
• DOI: 10.1136/bmjqs-2016-IHIabstracts.23
• Languages: English
• ISSNs: 2044-5415

Abstract

Abstract : Background: Handoff miscommunications are a leading source of medical errors. Error rates decreased following implementation of the I-PASS handoff program (a bundled intervention using a structured mnemonic, I-PASS, and other initiatives to sustain implementation) in a pediatric research trial. Whether I-PASS can be implemented in settings outside academic pediatric institutions is unknown. Objectives: To implement I-PASS in a variety of hospitals and medical specialties using a mentored process. (2) To measure the association of I-PASS implementation with handoff quality and provider-reported medical error rates. Methods: We implemented I-PASS in 16 hospitals [community (n=5), academic (n=11)] and multiple specialties [internal medicine (n=7), pediatrics (n=3), other (n=6)]. We paired each site with an external mentorship team of I-PASS experts that conducted a site visit and provided ongoing coaching. Site leads participated in program wide webinars and shared data with participating sites. Validated handoff observation tools and a provider survey assessed handoff quality and rates of adverse events. Results: Implementation was associated with increased inclusion of all 5 I-PASS mnemonic elements for both verbal (14% vs 70%) and written (0% vs 81%) handoffs. Additionally, increases were noted in the frequency of high quality verbal (44% vs 81%) and written (49% vs 73%) patient summaries, verbal (22% vs 82%) and written (44% vs 72%) contingency plans, and verbal receiver syntheses (4% vs 81%). Adverse events decreased by 27%. All changes statistically significant. Improvements were similar across provider types and settings. Conclusions: The I-PASS Handoff program is associated with improved handoff communication in a variety of settings and provider types.Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8