• Amy J Starmer, Nancy D Spector, Jennifer K O'Toole, Zia Bismilla, Sharon Calaman, Maria-Lucia Campos, Maitreya Coffey, Lauren A Destino, Jennifer L Everhart, Jenna Goldstein, Dionne A Graham, Jennifer H Hepps, Eric E Howell, Nicholas Kuzma, Greg Maynard, Patrice Melvin, Shilpa J Patel, Alina Popa, Glenn Rosenbluth, Jeffrey L Schnipper, Theodore C Sectish, Rajendu Srivastava, Daniel C West, Clifton E Yu, Christopher P Landrigan, and I-PASS SHM Mentored Implementation Study Group.
• Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
• J Hosp Med. 2023 Jan 1; 18 (1): 5145-14.

BackgroundHandoff 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.ObjectiveTo determine if I-PASS implementation across diverse settings would be associated with improvements in patient safety and communication.DesignProspective Type 2 Hybrid effectiveness implementation study.Settings And ParticipantsResidents from diverse specialties across 32 hospitals (12 community, 20 academic).InterventionExternal teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews.Main Outcome And MeasuresSystematic surveillance surveys assessed rates of resident-reported adverse events. Validated direct observation tools measured verbal and written handoff quality.Results2735 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).© 2022 Society of Hospital Medicine.

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