Communication failures contribute to two thirds of the most serious preventable adverse events in hospitals. Improving the quality of communication, especially "handoffs," has consequently been a leading patient safety goal of the Agency for Healthcare Research and Quality (AHRQ) and the Joint Commission. Until recently, however, high-quality data demonstrating the effectiveness of handoff improvement efforts were lacking. We conducted a pilot project at Boston Children's Hospital in which we found that implementation of a bundle of training and process change interventions designed to improve handoffs was associated with reductions in handoff miscommunications, improvements in resident-physician workflow (less time at the computer, more time in direct patient care), and most importantly, a significant reduction in serious medical errors. With funding from the Department of Health and Human Services (R18 AE000029), we refined and expanded this bundle as the I-PASS program, which includes multi-modal delivery of teamwork and handoff training (built in part on AHRQ's and the Department of Defense's TeamSTEPPS program), handoff simulation training exercises, introduction of a verbal mnemonic, changes to the verbal handoff process (including teamwork process and environment changes), a printed handoff tool, faculty development materials, and a culture change campaign. In a 9-center study, we have found that following implementation of I-PASS across sites, errors that harmed patients (preventable adverse events) fell 34%, and near misses / non-harmful medical errors fell 26%. As handoff problems continue to be a major source of morbidity and mortality in hospitals, we believe that dissemination and implementation of I-PASS could have an important impact on patient safety. The Society of Hospital Medicine has developed a robust methodology, Mentored Implementation, which has been used to broadly disseminate numerous patient safety and quality interventions to hospitals nationwide;the National Quality Forum and the Joint Commission awarded the Mentored Implementation program the 2011 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National Level, in recognition of its tremendous successes effectively disseminating safety and quality of care interventions. We propose to adapt and implement I-PASS in collaboration with the Society of Hospital Medicine (SHM) and the Pediatric Research in Inpatient Settings (PRIS) network, employing SHM's Mentored Implementation methodology.
Our specific aims will be: 1) To develop a robust process for implementing and disseminating I- PASS through the Society for Hospital Medicine's Mentored Implementation Program;2) To effectively enact the I-PASS Mentored Implementation Program in 32 teaching hospitals;and 3) To build a toolkit to promote widespread dissemination of I-PASS through the Pediatric Research in Inpatient Settings Network, the Society for Hospital Medicine, and beyond.

Public Health Relevance

Communication failures are a leading cause of serious errors in hospitals. We have developed I-PASS, a bundle of evidence-based handoff practices and tools that decrease miscommunications;in a nine-center study, we found that errors that harmed patients decreased 34% following implementation of I-PASS, and near misses decreased 26%. We propose to implement I-PASS in 32 adult and pediatric hospitals through the Society of Hospital Medicine's award-winning Mentored Implementation program.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Special Emphasis Panel (ZHS1-HSR-F (01))
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Harrison, Michael
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Children's Hospital Boston
United States
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