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Automation of the I-PASS Tool to Improve Transitions of Care

Skaret, Michael M.; Weaver, Travis D.; Humes, Ross J.; Carbone, Thomas V.; Grasso, Ian A.; Kumar, Harjinder

The Journal for Healthcare Quality (JHQ): September/October 2019 - Volume 41 - Issue 5 - p 274–280
doi: 10.1097/JHQ.0000000000000174
Original Article

Introduction: Errors in communication during handoffs are a significant source of medical error and put patients at risk. The I-PASS system was designed to systematically communicate information to the oncoming healthcare provider and has been shown to decrease the risk of communication errors. The objective of this observational quality improvement study was to determine whether the addition of a partially automated, electronic handoff tool would further decrease errors in communication during transitions of care for inpatient medical teams.

Methods: We created an electronic tool to incorporate user-generated patient information in the I-PASS format with automatically compiled data derived from the electronic medical record. Numbers of errors in the printed handoff document were recorded before and after intervention.

Results: The first implementation cycle demonstrated an absolute risk reduction for written errors of 45.6% (95% confidence interval [CI] 39.2–51.2%) and a number needed to treat (NNT) of three patients. The second cycle showed an absolute risk reduction of 53.3% (95% CI 39.8–63.9%; NNT 2). Aggregate data showed an absolute risk reduction of 46.6% (95% CI 41.0–51.7%, NNT 3).

Conclusions: Improving the routine task of patient handoff through the thoughtful application of technology can yield benefits in terms of decreasing documentation errors and streamlining workflow before patient handoff.

For more information on this article, contact Michael M. Skaret at

The authors declare no conflicts of interest.

Received May 07, 2018

Accepted September 03, 2018

© 2019 National Association for Healthcare Quality
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