Implementation of the I‐PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. Issue 1 (3rd November 2022)

• Record Type: Journal Article
• Authors: Starmer, Amy J.; Spector, Nancy D.; O'Toole, Jennifer K.; Bismilla, Zia; Calaman, Sharon; Campos, Maria‐Lucia; Coffey, Maitreya; Destino, Lauren A.; Everhart, Jennifer L.; Goldstein, Jenna; Graham, Dionne A.; Hepps, Jennifer H.; Howell, Eric E.; Kuzma, Nicholas; Maynard, Greg; Melvin, Patrice; Patel, Shilpa J.; Popa, Alina; Rosenbluth, Glenn; Schnipper, Jeffrey L.; Sectish, Theodore C.; Srivastava, Rajendu; West, Daniel C.; Yu, Clifton E.; Landrigan, Christopher P.
• Other Names: Edgar‐Zarate Courtney investigator.; Boa‐Hocbo Aileen investigator.; Zampino Dominick investigator.; Rosenbluth Glenn investigator.; West Daniel C. investigator.; Campos Maria‐Lucia investigator.; Melvin Patrice investigator.; Graham Dionne A investigator.; Landrigan Christopher P. investigator.; Sectish Theodore C. investigator.; Starmer Amy J. investigator.; Menon Aravind Ajakumar investigator.; Sloan Karin A investigator.; Patel Rajesh investigator.; Mueller Stephanie investigator.; Schnipper Jeff investigator.; Eagle Steven investigator.; Marrese Christine investigator.; Serra Theresa investigator.; Etzenhouser Angie investigator.; Mann Keith investigator.; Riss Robert investigator.; Seltz Barry investigator.; Kothari Lara investigator.; Sheppard Kathleen investigator.; Scholtz Amy investigator.; Mack Avram investigator.; Anson Elizabeth investigator.; Barber Aisha investigator.; Kern Jeremy investigator.; O'Toole Jennifer K. investigator.; Bates Kimberly investigator.; Kaplan Peter investigator.; Mehta Bijal investigator.; Bismilla Zia investigator.; Coffey Maitreya investigator.; Campe Julie investigator.; Kaatz Scott investigator.; Hanna‐Attisha Mona investigator.; Vaniawala Vishwas investigator.; Stevens Scott M. investigator.; Hughes Helen investigator.; Ngo Thuy L. investigator.; Serwint Janet investigator.; Patel Shilpa J. investigator.; Gaspar‐Oishi Maria investigator.; Hiraoka Mark investigator.; Doroshow Jonathan investigator.; Surkis William investigator.; Marseille David investigator.; Webster Mary investigator.; Destino Lauren A. investigator.; Everhart Jennifer L. investigator.; Hecht Melvyn investigator.; Kantrowitz Michael investigator.; Galardy Paul investigator.; Huskins Charles investigator.; Kashiwagi Deanne investigator.; Southgate Michael W. investigator.; Bhan Renuka investigator.; Hanlon Charin investigator.; Cohen Ellen investigator.; Srivastava Rajendu investigator.; Kanala Vishnu investigator.; Howell Eric E. investigator.; Mallouk Meghan investigator.; Nolan Ann investigator.; Nyenpan Christopher investigator.; Goldstein Jenna investigator.; Maynard Greg investigator.; Owolabi Mobola investigator.; Khan Nazia Naz S. investigator.; Calaman Sharon investigator.; Kuzma Nicholas investigator.; Spector Nancy D. investigator.; Weinerman Adina investigator.; Kaul Rajat investigator.; LeRoux Laura investigator.; Dupont Katharine investigator.; Mims Lisa investigator.; Reppert Patrick investigator.; Bordin‐Wosk Talya investigator.; Popa Alina investigator.; Ali Arshia investigator.; Clark Katherine investigator.; Held Justin investigator.; Thangarasu Sudhagar investigator.; Lacy Mary investigator.; Roesch Justin investigator.; Brooks Michelle investigator.; Yu Clifton E. investigator.; Hepps Jennifer H. investigator.;
• Is Part Of: Journal of hospital medicine. Volume 18:Issue 1(2023)
• Page Start: 5
• Page End: 14
• Publication Date: 2022-11-03
• Subjects: Hospital care -- Periodicals; Clinical medicine -- Periodicals; 610
• DOI: 10.1002/jhm.12979
• Languages: English
• ISSNs: 1553-5592

Abstract

Abstract: 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).