Executive Summary

Medical errors due to communication failures are a leading cause of preventable harm and service failures. Transitions of patient care, also referred to as handoffs, occur when patient responsibility transfers from one health care provider or hospital unit to another (e.g., during change of shift or when a patient moves from a general inpatient unit to an intensive care unit). These handoffs are a particularly vulnerable time for communication failures and can lead to errors and patient harm. 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. 

The I-PASS Patient Safety Institute understands that problematic, unstructured handoff communication presents a significant vulnerability and risk to patients. Our goal is to standardize transitions of care between clinicians while mitigating handoff-related communication failures to ultimately reduce medical errors and improve patient safety. 

When all frontline clinicians use I-PASS as the “common language” for care transitions, improvements in patient perceptions of teamwork, and staff satisfaction with handoffs are positive derivatives of reliable handoff communication. We look forward to supporting the advancement of internal patient safety initiatives and collaboratively partnering with your team in your pursuit of Zero Preventable Harm.

Key Markers of Success

1. Development, implementation, and refinement of the Implementation Plan
2. Implementation of a Standardized Written Handoff tool for use by all in-scope clinicians
3. Organization-wide Virtual Training on the I-PASS methodology for verbal and written handoffs
4. Continuous Observation, Assessment, and real-time feedback to translate I-PASS Training education into repeatable safety-based behavior across your organization
5. Development of a Sustainment Plan to support long-term durability and continued improvement of the I-PASS Handoff methodology