Healthcare Analytics, Population Health Management, Healthcare Big Data


Care Coordination Technique Reduces Medical Errors by 30%

By Jennifer Bresnick

Pediatric residents who used the “I-PASS” system reduced medical errors and improved satisfaction with transitions of care.

- A simple mnemonic device can help providers improve care coordination and reduce patient safety issues and medical errors by nearly one-third, according to a study published in The New England Journal of Medicine.  The “I-PASS” program helped cut preventable injuries due to medical errors by 30% in a number of pediatric hospitals, but did not unduly increase the time it took to conduct handoffs for clinical staff.

Nine academic medical centers participated in the study, which provided three hours of training to pediatric residents about the I-PASS method and the importance of ensuring thorough communication during transitions of care.  The training involved role playing and EHR training to help residents consistently apply good communication strategies during a shift change or other handoff event.


With use of the device, medical errors decreased from 4.7 per 100 admissions to 3.3 errors per 100 admissions, which is a decline of thirty percent.  The researchers noted a measurable increase in the quality of documentation provided by residents during a shift change, and also found that clinical staff reported higher levels of satisfaction with the handoff process after using the I-PASS methodology.

“This study suggests that a standardized process along with education and information technology support can reduce medical errors,” said study co-author F. Sessions Cole, MD, vice chair of the Department of Pediatrics at Washington University and chief medical officer of St. Louis Children’s Hospital.

“We recognized that it would take a great deal of work to make the handoff program a sustainable system and encourage its adoption across hospitals,” added Amy Starmer, MD, of Boston Children’s Hospital and Harvard Medical School. “We partnered with experts in research, curriculum development and administration, as well as local faculty and executives at the nine centers, to develop a comprehensive and multifaceted handoff and communication program. Now the new I-PASS program works seamlessly with existing tools and is part of each institution’s culture.”

The study was funded by a grant from the Department of Health and Human Services and involved hospitals in Missouri, California, Ohio, Oregon, Toronto, Utah, and Pennsylvania as well as the Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences.

The team also hopes to expand use of the I-PASS system beyond its current scope. “With the support of funding through PCORI, we plan to address this issue by incorporating I-PASS into family-centered rounds and communication processes and measuring the effects on patient safety, patient/family experience, and care processes,” a website dedicated to the study says. “Doing so will bring together two transformative communication interventions: 1) the I-PASS Handoff Bundle which that has been demonstrated to decrease medical errors and written and verbal miscommunications; and 2) an initiative to more effectively incorporate patients and families into healthcare communication and decision making.”


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