Journal Article

I-PASS handoff program: use of a campaign to effect transformational change.

Rosenbluth G, Destino LA, Starmer AJ, et al. Pediatric quality & safety. 2018;3:e088.

Patient handoffs carry high risk for errors. I-PASS is a structured handoff tool that reduces errors and preventable adverse events. Investigators noted that substantial culture change was required to implement I-PASS in the nine hospitals in which it was initially studied. In this study, they describe the organizational transformation techniques that fostered widespread I-PASS adoption. Tangible elements included establishing a sense of urgency, developing a memorable multimedia campaign, and engaging health care system and educational leaders. Their successes and lessons learned may provide a roadmap for implementing other evidence-based safety campaigns at academic centers. Two WebM&M commentaries explore the risks of handoffs and how to mitigate them. A PSNet interview discussed handoffs and the implementation and findings of the landmark I-PASS study.