About the I-PASS Study


The I-PASS Study was initiated in response to mounting evidence that communication and handoff failures are a root cause of two-thirds of “sentinel events” – serious, often fatal, preventable adverse events in hospitals.

The Agency on Healthcare Research and Quality (AHRQ) and Joint Commission has identified improving handoffs in care as a priority in nationwide efforts to improve patient safety. Research on handoff tools and processes has identified team training, introduction of verbal mnemonics, and use of written or computerized tools as strategies to improve handoffs and reduce medical errors.

Overview: The I-PASS Study

The I-PASS Study aims to implement a standardized, evidence-based handoff program comprised of the innovative I-PASS Handoff Bundle (including team training, a verbal mnemonic, and a structured printed tool) and to rigorously measure its impact on medical errors, verbal and written miscommunications, and resident physician workflow and satisfaction. The I-PASS Study is an ongoing collaborative effort that aims to determine the effectiveness of the I-PASS Handoff Bundle in standardizing and improving handoffs. In a pilot study, a similar intervention was associated with a 40% reduction in medical errors and significant decreases in both verbal and written miscommunication rates.

A total of nine hospitals in the United States and Canada serve as data collection sites for the study. Staggered six-month waves of baseline data collection of medical errors and resident workflow, satisfaction, and miscommunications began in January 2010. Each site has a six-month wash-in period to implement the I-PASS Handoff Bundle intervention before embarking upon an additional six months of post-intervention data collection. The data collection for the I-PASS Study is scheduled to be completed in May 2013.

I-PASS Study Group

The I-PASS Study Group includes over 50 faculty from across North America with expertise in health services research, faculty development, medical simulation, curriculum development, and change management. The Pediatric Research in Inpatient Settings (PRIS) Network and the Initiative for Innovation in Pediatrics Education (IIPE) contribute to the management and oversight of the I-PASS Study. Some content in the I-PASS Handoff Curriculum includes materials adapted from TeamSTEPPS®, an evidence-based teamwork curriculum developed by the Agency for Healthcare Research and Quality and the Department of Defense Patient Safety Program.

I-PASS Events

One of the Top Downloaded Publications for 2013 on MedEdPORTAL


Accreditation Canada Leading Practices, Award Recipient (2013)

AAMC Readiness For Reform (R4R) Health Care Innovation Challenge – Honorable Mention (2012)

Ray E. Helfer Award for Innovation in Pediatric Education – Award Recipient (2011)