What Is The I-PASS Resident Handoff Bundle and Why Can It Save Patient Lives

November 22, 2014

When big pharma launches a new drug that can save or prolong lives, it is met with great fanfare and widespread news coverage, but a recent study proves that it does not take always take ‘rocket-science’ or the discovery of a new drug compound to save a significant number of patient lives.

The specific numbers vary, but medical errors are estimated to kill hundreds of thousands of Americans in US hospitals every year. However, the large majority of these errors and the deaths they cause are preventable and according to the Joint Commission, the root cause in most situations is care team communication failures.

In November 2014, researchers from several prominent US academic medical centers shared their findings from a large, prospective, multi-center, research trial that investigated an intervention that standardized handoff communications between inpatient pediatric medical providers coming on and off duty. In the clinical study, which they named, the IPASS study*, the researchers found that after the intervention, as compared to before the intervention, medical error rates decreased significantly (to see the study results see the New England Journal of Medicine (NEJM) 2014; 371:1803-12.

One of the key components of the intervention was something the researchers call a Resident Training Bundle or IPASS Training Bundle. So what exactly is a resident handoff bundle? Well according to the study, a Resident Handoff Bundle has three components (the specific detail, see the the NEJM and

  • A mnemonic (IPASS) for standardizing verbal and paper (written and/or computer generated) handoff communications
  • Communications, teamwork and handoff skills training (didactic workshop, role playing, computer module, faculty development program)
  • An ongoing process and culture change campaign led by clinical and administrative facility leadership

The work of the IPASS investigators is something about which all hospital administrators and clinical leaders should take note. While implementing organizational change may be harder than purchasing and administering a new pharmaceutical, in the case of standardizing handoffs, the consequences of failing to standardize this important workflow in US hospitals may result in the unfortunate death of potentially more than 200,000 Americans every year.

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* The IPASS study was supported by the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (1R18AE000029-01). Other grant funding for the study was provided by Agency for Healthcare Research and Quality (1K12HS019456-01), the Medical Research Foundation of Oregon, the Physician Services Incorporated Foundation (of Ontario, Canada), and by an unrestricted medical education grant from Pfizer.