I-PASS Patient Safety Institute

Medical errors due to communication failures are a leading cause of harm and death in patients in the United States. Transitions of patient care, also referred to as handoffs, occur when the responsibility for patient care moves from one health care provider or hospital unit to another (e.g. during change of shift from day to evening or when a patient moves from a general inpatient unit to an inte

nsive care unit). These handoffs are a particularly vulnerable time for communication failures that lead to errors and patient harm. In fact, analysis by the Joint Commission has identified communication and handoff failures as a contributing root cause of more than two-thirds of the most serious errors that harm patients. I-PASS is an evidence-based package of interventions created to reduce communication failures during patient handoffs. A patient handoff occurs each time there is a shift change between medical professionals, as well as when a patient is transferred from one department in a hospital to another department. An average sized hospital, based on an estimated 2 to 3 handoffs per patient, per day, will have approximately 1.6 million handoffs per year. Historically, the process for conducting high quality handoffs within health care settings has not been formally taught to doctors or nurses; they are non-standardized, and vary both within an institution and between institutions. When an incomplete or incorrect handoff is conducted, a medical error may arise. The I-PASS Handoff Method was created by the I-PASS Study Group. In a multi-centered study, the I-PASS Study Group demonstrated that implementation of the I-PASS Handoff Method was associated with a 30% reduction in errors that harm patients. The I-PASS Handoff Method has been adapted for use by physicians and nurses in a broad range of clinical settings. Widespread implementation of the I-PASS Handoff Method in hospitals across the United States could save thousands of lives and billions of dollars of health care costs each year. With our program, hospitals can implement I-PASS using a fraction of the time and resources they would spend doing it themselves. I-PASS is a package of interventions that has been created over the years from the various studies, building on the original I-PASS mnemonic (a pattern of letters acting as a memory aide) and a series of complementary interventions designed to improve patterns of hospital communication. To drive significant changes in patient safety, I-PASS needs to be systematically adopted and used daily by health care professionals in their written and oral communications. We work with hospitals to create a customized program to ensure adoption and longterm sustainment of I-PASS. I-PASS can be implemented in individual departments, but for the greatest benefit, it should be adopted throughout an entire institution. We work with institutions to develop an implementation plan that best meets the hospital’s / department’s goals. Based on the I-PASS Study Group’s experience implementing the I-PASS Handoff Method in specific departments or clinical units of over 70 institutions across North America, they have identified several significant barriers to large-scale implementation. The I-PASS Patient Safety Institute was founded to develop solutions to overcome these barriers and allow for a quicker, more efficient, implementation of the I-PASS Handoff Method. Specifically, the I-PASS Patient Safety Institute has developed cloud-based and mobile applications, integrated with best practices offered by implementation science as well as the experience of the senior I-PASS coaches, which allow the institutions to deploy the I-PASS Handoff Method more efficiently and effectively. The I-PASS Patient Safety Institute is a mission-driven company founded by the leadership of the I-PASS Study Group. That leadership group is integrally involved in the direction and execution of the I-PASS Patient Safety Institute. The I-PASS Patient Safety Institute is focused on helping hospitals and health systems with large-scale implementation and sustainment of the I-PASS Handoff Method in order to reduce medical errors that occur during patient handoffs and transitions of care.