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Journal of Hospital Medicine Study Shows I-PASS Implementation Helps Reduce Patient Harm and Improve Communication Quality

Journal of Hospital Medicine Study Shows I-PASS Implementation Helps Reduce Patient Harm and Improve Communication Quality

The platform assists care teams in highly reliable handoffs that drive improved patient outcomes and transfers of knowledge with fewer communication failures.

BOSTON, Mass. – NOV 3, 2022I-PASS, the go-to method for reducing medical error and patient harm for hundreds of hospitals and healthcare providers nationwide, was recently featured in the “Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study” published in the Journal of Hospital Medicine.

The study was conducted across 32 community and academic hospitals and found that both major and minor hand-off-related reported adverse events decreased by 47% following implementation. Additionally, I-PASS implementation was associated with the inclusion of all five key handoff data elements in verbal and written handoffs, as well as increased frequency of handoffs with high-quality verbal and written patient summaries across adult and pediatric provider types.

The purpose of the study was to examine how handoff miscommunications, the leading source of medical errors, could be decreased across specialties with the implementation of the I-PASS handoff improvement program. The findings of the study, published on behalf of the 92-member study group, including Chris Landrigan, MD, MPH Co-Founder of the I-PASS Patient Safety Institute and Chief of General Pediatrics at Boston Children’s Hospital, highlighted the efficacy of implementing seamless care transitions across adult and pediatric specialties to aid in the reduction of patient harm. For more than a decade, the I-PASS handoff program has been associated with significantly reduced miscommunications, medical errors, and injuries due to medical errors.

“The transfer of patient information between healthcare providers is a known point of vulnerability which can lead to communication failures that result in patient harm and medical malpractice cases,” Dr. Landrigan said. “By implementing evidence-based, standardized handoff communication tools designed to address and reduce knowledge gaps among providers, healthcare organizations are able to overcome organizational barriers and aid in behavior change to help reduce errors and costs associated with malpractice claims. The data shows that implementation of the I-PASS handoff communication tools can result in significant improvements that benefit patients and health systems.”

Previous studies have shown that communication failures are a contributing cause in two out of every three sentinel events, which are the most serious adverse events in hospitals. Communication breakdowns can occur across multiple points in the care journey of a patient. Failure to clearly communicate contingency plans, patient diagnosis, and severity of illness have been found to be some of the most frequent sources of communication failures.

“The findings of our research provide substantial evidence that existing policies should evolve to strongly incentivize the adoption of high-quality, multifaceted handoff programs to further advance patient safety,” said Amy Starmer, MD, MPH, Associate Medical Director of Quality at Boston Children’s Hospital in the Department of Pediatrics and Co-founder of the I-PASS Patient Safety Institute. “Annually, thousands of patients are impacted by adverse events related to communication failures that may have been avoided with proper handoffs. By implementing a standardized process like I-PASS, clinicians can share consistent and highly reliable clinical information using an efficient structure that ensures providers have accurate and critical patient information.”

“Our team is excited to see the results of this study as they underscore the vital need for services that streamline the transition of care and information among providers across specialties,” said William Floyd, CEO of the I-PASS Patient Safety Institute. “For years, providers and health systems have been looking for solutions and tools that address systemic risks, such as communication. This study reinforces the findings of past studies that found I-PASS to be a highly reliable tool that improves patient safety and empowers providers to deliver the best care possible.”

To read the full study in the Journal of Hospital Medicine, click here.

Dr. Landrigan is a co-founder, equity holder, serves on the Board of Directors, and is a scientific advisor for the I-PASS Patient Safety Institute. Dr. Landrigan receives compensation for the scientific advisor role. Dr. Starmer is a co-founder, equity holder, and has received compensation for consulting with the I-PASS Patient Safety Institute. Boston Children’s Hospital is also an equity holder in the I-PASS Patient Safety Institute.


About I-PASS

The I-PASS Patient Safety Institute is a clinical leader in patient safety, enabling a standard of care for patient handoffs and closed-loop communication. Founded by clinicians in 2016, the I-PASS Institute leverages expert mentorship paired with technology and digital tools to scale the I-PASS methodology. The I-PASS Institute’s solution, the I-PASS Bundle, consists of three core technical components—I-PASS Training, I-PASS Assessment and Improvement, and I-PASS eVIEW. When all three platforms are used in unison and with the guidance of an expert coach, institutions are able to reduce patient harm caused by miscommunication. Currently implemented in more than 100 institutions, the organization’s clients span high-reliability organizations, from pediatrics and residency programs to nursing and transition of care with families. Learn more at

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