I-PASS handover system: a decade of evidence demands action.

David M Shahian

Commentary

I-PASS handover system: a decade of evidence demands action.

May 12, 2021

Shahian DM. BMJ Qual Saf. 2021;30(10):769-774.

View more articles from the same authors.

The I-PASS structured handoff tool aims to improve communication during patient transfers and reduce errors and preventable adverse events. This editorial summarizes evidence supporting I-PASS implementation and the challenge of rigorously assessing the association between handoffs and adverse events, medical errors, and other clinical outcomes.

PubMed citation

Free full text

Related study

Related Resources From the Same Author(s)

Time out! Rethinking surgical safety: more than just a checklist.

April 28, 2021

The problem with…using stories as a source of evidence and learning.

March 9, 2022

Safety cases for digital health innovations: can they work?

July 14, 2021

Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg.

June 15, 2022

Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study.

May 11, 2022

The husband's story: from tragedy to learning and action.

June 10, 2015

A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hospitalised patient outcomes.

August 3, 2022

The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and improve safety.

May 5, 2021

Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges.

November 3, 2021

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Research to improve diagnosis: time to study the real world.

January 26, 2022

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

April 27, 2022

Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity.

May 4, 2022

How safe are paediatric emergency departments? A national prospective cohort study.

August 3, 2022

Improving responses to safety incidents: we need to talk about justice.

February 23, 2022

Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations.

August 4, 2021

The problem with making Safety-II work in healthcare.

April 13, 2022

Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.

April 14, 2021

Interventions targeted at reducing diagnostic error: systematic review.

September 8, 2021

Use of e-triggers to identify diagnostic errors in the paediatric ED.

April 6, 2022

The problem with 'My Five Moments for Hand Hygiene'.

August 25, 2021

Should electronic differential diagnosis support be used early or late in the diagnostic process? A multicentre experimental study of Isabel.

October 27, 2021

July 20, 2022

Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD).

September 15, 2021

Associations of workflow disruptions in the operating room with surgical outcomes: a systematic review and narrative synthesis.

June 17, 2020

Managing teamwork in the face of pandemic: evidence-based tips.

June 24, 2020

Safety implications of remote assessments for suspected COVID-19: qualitative study in UK primary care.

March 23, 2022

Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies.

June 8, 2022

Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review.

February 16, 2022

Remedies sought and obtained in healthcare complaints.

September 7, 2011

Effects of tall man lettering on the visual behaviour of critical care nurses while identifying syringe drug labels: a randomised in situ simulation.

April 20, 2022

Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices.

June 30, 2021

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

May 19, 2021

Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings.

August 24, 2022

Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme.

June 22, 2022

Crisis checklists in emergency medicine: another step forward for cognitive aids.

April 7, 2021

Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial.

March 17, 2021

Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.

March 3, 2021

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

Timeout procedure in paediatric surgery: effective tool or lip service? A randomised prospective observational study.

March 24, 2021

Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs.

March 10, 2021

Documenting the indication for antimicrobial prescribing: a scoping review.

November 2, 2022

Outcome differences between surgeons performing first and subsequent coronary artery bypass grafting procedures in a day: a retrospective comparative cohort study.

June 29, 2022

Tiered daily huddles: the power of teamwork in managing large healthcare organisations.

October 7, 2020

February 2, 2022

National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies.

May 25, 2022

Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey.

February 16, 2022

Chronic hospital nurse understaffing meets COVID-19: an observational study.

September 9, 2020

We're all in this together: how COVID-19 revealed the co-construction of mindful organising and organisational reliability.

February 9, 2022

Factors influencing physician responsiveness to nurse-initiated communication: a qualitative study.

December 2, 2020

Inpatient patient safety events in vulnerable populations: a retrospective cohort study.

November 18, 2020

Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study.

December 23, 2020

Effects of CPOE-based medication ordering on outcomes: an overview of systematic reviews.

July 8, 2020

Emotional safety is patient safety.

February 15, 2023

The debrief imperative: building teaming competencies and team effectiveness.

November 16, 2022

Retrospective analysis of reported suicide deaths and attempts on veterans health administration campuses and inpatient units.

September 23, 2020

Identifying and encouraging high-quality healthcare: an analysis of the content and aims of patient letters of compliment.

August 5, 2020

Vulnerability of the medical product supply chain: the wake-up call of COVID-19.

November 25, 2020

Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients.

August 26, 2020

How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist grounded theory.

October 19, 2022

Quality improvement as a primary approach to change in healthcare: a precarious, self-limiting choice?

December 7, 2022

Economic evaluation of quality improvement interventions to prevent catheter-associated urinary tract infections in the hospital setting: a systematic review.

March 30, 2022

Changing hospital organisational culture for improved patient outcomes: developing and implementing the Leadership Saves Lives intervention.

August 12, 2020

Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services.

February 3, 2016

August 19, 2020

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.

December 16, 2020

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study.

July 29, 2020

Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study.

September 16, 2020

A realist synthesis of pharmacist-conducted medication reviews in primary care after leaving hospital: what works for whom and why?

December 2, 2020

Improving diagnostic performance through feedback: the Diagnosis Learning Cycle.

September 1, 2021

Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research.

May 9, 2018

The Irish National Adverse Event Study-2 (INAES-2): longitudinal trends in adverse event rates in the Irish healthcare system.

February 3, 2021

Diagnostic errors in the intensive care unit: a systematic review of autopsy studies.

August 8, 2012

A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study.

January 8, 2014

Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system.

May 12, 2021

Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments.

October 26, 2022

Large-scale implementation of the I-PASS handover system at an academic medical centre.

March 22, 2017

Peer support by interprofessional health care providers in aftermath of patient safety incidents: a cross-sectional study.

June 9, 2021

Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records.

August 10, 2022

Peers without fears? Barriers to effective communication among primary care physicians and oncologists about diagnostic delays in cancer.

November 1, 2017

On higher ground: ethical reasoning and its relationship with error disclosure.

April 24, 2013

Making communication and resolution programmes mission critical in healthcare organisations.

November 11, 2020

Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis.

January 25, 2023

Reporting incidents involving the use of advanced medical technologies by nurses in home care: a cross-sectional survey and an analysis of registration data.

July 15, 2020

Impact of providing patients access to electronic health records on quality and safety of care: a systematic review and meta-analysis.

July 8, 2020

Safety culture and mortality after acute myocardial infarction: a study of Medicare beneficiaries at 171 hospitals.

October 25, 2017

Core competencies for patient safety research: a cornerstone for global capacity strengthening.

February 2, 2011

Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study.

January 9, 2019

Rating the raters: the inconsistent quality of health care performance measurement.

March 2, 2016

Variability in the measurement of hospital-wide mortality rates.

March 19, 2014

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy.

November 25, 2020

Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis.

April 5, 2023

Fall prevention implementation strategies in use at 60 United States hospitals: a descriptive study.

December 9, 2020

Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre.

July 22, 2020

Ensuring successful implementation of communication-and-resolution programmes.

March 18, 2020

Novel telephone-based interactive voice response system for incident reporting.

November 17, 2021

Moving beyond the weekend effect: how can we best target interventions to improve patient care?

June 30, 2021

'Immunising' physicians against availability bias in diagnostic reasoning: a randomised controlled experiment.

March 18, 2020

Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes.

June 30, 2021

Expert consensus on currently accepted measures of harm.

September 9, 2020

Related Resources

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Medication safety event reporting: factors that contribute to safety events during times of organizational stress.

May 24, 2023

Towards a unified model of accident causation: refining and validating the systems thinking safety tenets.

May 10, 2023

Events that inspired change: the importance of sharing what happened to stop it from happening again.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Patient Safety Primers

Patient Safety Indicators.

April 26, 2023

Quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach.

April 19, 2023

Reducing risks in complex care transitions in rural areas: a grounded theory.

March 22, 2023

Hospital discharge and readmission.

March 2, 2023

A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic.

January 18, 2023

An asset-based quality improvement tool for health care organizations: cultivating organization wide quality improvement and health care professional engagement.

October 19, 2022

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

Patient safety: where to aim when zero harm is not the target-a case for learning and resilience.

August 31, 2022

Positive approaches to safety: learning from what we do well.

August 31, 2022

Acute clinical deterioration and consumer escalation: the understanding and perceptions of hospital staff.

August 31, 2022

Who killed patient safety?

July 20, 2022

Handoffs and teamwork: a framework for care transition communication.

June 29, 2022

Establishing a multidisciplinary taskforce to improve anticoagulation safety at a large health system.

December 12, 2021

Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds.

October 27, 2021

The impact of hospital accreditation on the quality of healthcare: a systematic literature review.

October 27, 2021

It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals.

October 13, 2021

The perfect storm: exam of a medical error and factors contributing to its possible escalation.

June 23, 2021

Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff.

June 16, 2021

Critical incidents involving the medical emergency team: a 5-year retrospective assessment for healthcare improvement.

April 28, 2021

Taking action to close the loop on diagnostic error: a Constellation and SIDM Collaborative.

June 1, 2021 - June 1, 2022

From fable to reality at Parkland Hospital: the impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient environment.

February 10, 2021

System issues leading to "found-on-floor" incidents: a multi-incident analysis.

January 27, 2021

See More About The Topic

Hospitals

Quality and Safety Professionals

Hospital Medicine

Nursing

Discontinuities, Gaps, and Hand-Off Problems

I-PASS handover system: a decade of evidence demands action.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Patient Safety Indicators.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

I-PASS handover system: a decade of evidence demands action.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Patient Safety Indicators.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site