I-PASS Reduces Medical Error Injuries During Patient Handoff by 30%

Walter Reed Bethesda and Uniformed Services University Part of Core Leadership of Multicenter Patient-Safety Study Proven to Reduce Injuries from Hospital Errors


Newswise — Bethesda - Improvements in verbal and written communication between health care providers during patient hand-offs can reduce injuries due to medical errors.

Reported in the Nov. 6, 2014, New England Journal of Medicine, researchers at Walter Reed National Military Medical Center (WRNMMC) and the Uniformed Services University of Health Sciences (USU) recognized this critical safety concern and teamed up with nine civilian hospitals to develop I-PASS, an original system of bundled communication and team-training tools for hand-off of patient care between providers. The study revealed a remarkable 30% reduction in injuries due to medical errors after its implementation across all 9 institutions.

According to the Joint Commission (a non-profit organization that accredits and certifies more than 20,500 health care organizations and programs in the United States and whose accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards), ineffective hand-off communication is recognized as a critical patient safety problem in health care; in fact, an estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients. The hand-off process involves “givers,” those caregivers transmitting patient information and transitioning the care of a patient to the next clinician, and “receivers,” those care-givers who accept the patient information and care of that patient. In addition to causing patient harm, defective hand-offs can lead to delays in treatment, inappropriate treatment, and increased length of stay in the hospital.

As the first military hospital to adopt the I-PASS hand-off bundle, which includes training in team communication skills, a verbal hand-off process organized around the verbal mnemonic “I-PASS” (Illness severity, Patient summary, Action List, Situational awareness and contingency planning, and Synthesis by receiver), a written or computerized hand-off tool that reflects the verbal mnemonic, a faculty development and observation program, and an institutional dissemination campaign, Walter Reed Bethesda has now implemented I-PASS for use across multiple disciplines to create an institutional transition of care policy.

According to one of the lead investigators COL Clifton E. Yu, Chief, Graduate Medical Education at Walter Reed Bethesda, “Not only is Walter Reed National Military Medical Center the only military hospital to be involved in the study, but we are also the only study site that was not a major children’s hospital. Taking advantage of that fact, we decided to work towards adapting the curriculum for dissemination across multiple clinical areas, to include adult medicine, surgery, and nursing environments. As our successful institutional roll out is evolving, we are setting the national standard and precedent for the use of I-PASS in all clinical and nursing domains where transitions of patient care typically occur.”

“Training in team communication skills is a critical element of the I-PASS Hand-off Bundle and, given the DoD Patient Safety Program’s longstanding interest and expertise in this area through their initial development of the TeamSTEPPS program (Team Strategies and Tools to Enhance Performance and Patient Safety, now jointly sponsored by the Agency for Healthcare Research and Quality), it seemed a natural fit to have WRNMMC and USU investigators take the lead on developing this aspect of the I-PASS curriculum. After completing training as a TeamSTEPPS Master Trainer, I was able to leverage my new knowledge and skills in order to adopt key elements of TeamSTEPPS into the team communication skills training for I-PASS. As it happens, our inclusion of TeamSTEPPS components into I-PASS dovetails perfectly with WRNMMC’s current roll out of full TeamSTEPPS training hospital wide,” said Army Maj. (Dr.) Jennifer Hepps, assistant professor of Pediatrics at USU.

“We were able to use the expertise of USU’s Val G. Hemming Simulation Center to create roleplays and videos simulating handover scenarios. These simulations helped to teach faculty and residents the best practices in transitions of care between patient teams,” said Joseph Lopreiato, M.D., MPH, professor of Pediatrics and associate dean of Simulation at USU. “Thanks to the support from the USU administration, our Simulation Center was able to contribute to this groundbreaking research that will go a long way toward reducing medical errors in the transitions of patient care.”

“Patients are at the center of everything we do," said Brig. Gen. Jeffrey B. Clark, director of the Walter Reed National Military Medical Center. "By quickly adopting the IPASS transitions of care principles for all healthcare teams, we simultaneously bring state of the art healthcare to our patients and teach the next generation of healthcare team members what right looks like.”

“A great medical team is like a great relay team: individual effort matters, but victory comes from smooth hand-offs,” said Arthur Kellermann, MD, dean of USU’s F. Edward Hébert School of Medicine.

Drs. Yu, Hepps, and Lopreiato are also co-investigators in two follow-on multi-center studies involving I-PASS at WRNMMC that include.– Family Centered I-PASS Projected funded by Patient Centered Outcomes Research Institute (PCORI), evaluating effectiveness of involving all team members, including nursing and families, in communication of medical information– Mentored I-PASS Implementation Project funded by Society for Hospital Medicine (SHM), examining how to implement I-PASS at other large academic medical institutions

Boston Children’s Hospital served as the lead site for the study, while Brigham and Women’s Hospital served as the data-coordinating center. Additional facilities that reported on the results of implementing I-PASS through their pediatric residency programs include:• Benioff Children’s Hospital, University of California San Francisco• Cincinnati Children’s Hospital Medical Center, University of Cincinnati• Doernbecher Children’s Hospital, Oregon Health Sciences University• Hospital for Sick Children, University of Toronto• Lucile Packard Children’s Hospital, Stanford University• Primary Children’s Hospital, University of Utah• St. Louis Children’s Hospital, Washington University St. Louis• St. Christopher’s Hospital for Children, Drexel University

Walter Reed National Military Medical Center, the world’s largest integrated military medical center, also known as the flagship of military medicine, where the nation heals our heroes, provides extraordinary experiences for patients, families, and staff while driving tomorrow’s healthcare advances through education, innovation and research.

The Uniformed Services University of the Health Sciences, founded by an act of Congress in 1972, is the nation’s federal health sciences university and the academic heart of the Military Health System. USU is located in Bethesda, Maryland, adjacent to the Walter Reed National Military Medical Center, and its students are primarily active duty uniformed officers in the Army, Navy, Air Force and Public Health Service who receive specialized education in tropical and infectious diseases, TBI and PTSD, disaster response and humanitarian assistance, global health, and acute trauma care. A large percentage of the university’s more than 5,200 physician and 1,000 advanced practice nursing alumni are supporting operations around the world, offering their leadership and expertise. USU also has graduate programs in clinical psychology, biomedical sciences, public health, and oral biology, which have awarded more than 1,500 degrees to date. The University's research program covers a wide range of clinical and basic science areas important to both the military and public health. For more information, visit www.usuhs.edu.

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