i-pass training

Overview: Transitions of Care & Medical Errors

Medical errors due to communication failures are a leading cause of harm and death in patients in the United States. In fact, according to the CDC, it was the third leading cause of death in 2018 with 167,127 deaths. Heart disease (655k) and cancer (599k) were the only other causes with more fatalities.



Transitions of patient care, also referred to as handoffs, occur when the responsibility for patient care moves from one health care provider or hospital unit to another (e.g. during a change of shift from day to evening or when a patient moves from a general inpatient unit to an intensive care unit).

An average-sized hospital, based on an estimated 2 to 3 handoffs per patient, per day, will have approximately 1.6 million handoffs per year.

These handoffs are a particularly vulnerable time for communication failures that lead to errors and patient harm. In fact, analysis by the Joint Commission has identified communication and handoff failures as a contributing root cause of more than two-thirds of the most serious errors that harm patients.


Medical errors are expensive and add significant costs to the U.S. healthcare system. In a 2015 study by CRICO, an insurance program serving the Harvard Medical Community that provides medical insurance products and patient safety resources to its members, it was determined that communication was a factor in 30% of malpractice cases studied from 2009 to 2013.

Those 7,149 cases that included communication errors as a contributing factor incurred $1.7 billion in losses, nearly $250,000 per case.

Per Case
U.S. healthcare system total losses

Additionally, provider to provider communication errors are more likely than the average of communication failures studied to result in a loss, and for an amount that is larger than the average.

I-PASS Patient Safety Institute understands that many hospitals have identified handoff communication as a significant vulnerability to process failure and risk to patients.

Implementing with the I-PASS Patient Safety Institute ensures sustained adherence to the I-PASS mnemonic structure over time and leads to reductions in harms to patients.

The goal of the I-PASS program is to systemize and standardize transitions of care and patient handoffs in order to mitigate the vulnerability to handoff-related communication failures and thereby reduce medical errors and improve patient safety.

In order to facilitate this goal, we have created a free to use malpractice calculator. Based on your number of inpatient admissions, the calculator will return your annual estimated savings from error reduction. Click the button below to give it a try!

Reduce Your Malpractice Claims

Background: I-PASS Hand-off Method

Patient Handoffs

Historically, the process for conducting high-quality handoffs within health care settings has not been formally taught to doctors or nurses; they are non-standardized and vary both within an institution and between institutions.

A great example of a poorly delivered handoff can be seen in our example video below.

Each handoff represents a critical moment in patient care. When an incomplete or incorrect handoff is conducted, a medical error may arise. Hopefully, Ms. Jones was still able to get the medical care she needed without any medical errors from the staff.

Standardizing Handoffs

The I-PASS handoff methodology can flip the script for institutions that operate with a non-standardized framework as seen in the video above. Ultimately, this can mean clearer communication, fewer medical errors, and decreased patient harm for your institution.

A great way to visualize how handoffs can be organized can be seen below. By organizing the handoff information within the I-PASS framework, information become much clearer for the person giving and receiving the handoff.


I-PASS Study Group

In a multi-centered study, the I-PASS Study Group demonstrated that implementation of the I-PASS Handoff Method was associated with a 30% reduction in errors that harm patients. The I-PASS Handoff Method has been adapted for use by physicians and nurses in a broad range of clinical settings.

Widespread implementation of the I-PASS Handoff Method in hospitals across the United States could save thousands of lives and billions of dollars of health care costs each year.


The successful use of I-PASS by medical professionals benefits all involved parties. Most importantly, the safety and health of the patient is improved. Additionally, medical professionals, hospitals, and medical insurers benefit from improved confidence and enhanced reputations and minimizing any negative social or psychological impacts, as well as reduce financial burdens that result from making errors that harm patients.

The reduction of medical errors eliminates costs from the healthcare systems, via decreased events caused by the errors, and also through the reduction in associated malpractice claims that may derive from such a medical error.

I-PASS Mnemonic

The Mnemonic

I-PASS Mnemonic provides a framework for the patient handoff process and includes 5 key elements that were determined by the I-PASS Study Group to be critically important for the handoff process.

The mnemonic takes the core component of the Patient Summary and surrounds it with frequently omitted, but vital, components of a patient handoff.

The I-PASS mnemonic framework 5 key elements:

  • I – Illness severity
  • P – Patient summary
  • A – Action list
  • S – Situation awareness and contingency planning
  • S – Synthesis by receiver

Below we will dive deeper into each of the five key elements that compose the I-PASS mnemonic.

I – Illness Severity

(ie., Stable, Watcher, Unstable)

Illness Severity clearly identifies the patient being handed over as either stable, unstable, or a “watcher.” This tells the oncoming clinician the overall status of the patient relative to their condition. For COVID-19 patients, you may indicate that a patient is “unstable” if they required a transfer to the ICU during the most recent shift.

  • Stable: Patients you are not worried about
  • Improving: Not acutely unstable but have the potential to worsen. A good example is a patient that looks comfortable on a high level of oxygen support. They are stable now, but given the degree of support, they have the potential to worsen.
  • Watch Closely: patients that are acutely ill/unstable.
  • Code Status

P – Patient Summary

(Summary statement; events leading up to admission, hospital course, ongoing assessment, plan)

The Patient Summary section provides a summary statement, or one-liner, that contains key identifying information, clinical context, a concise description, and synthesizes key elements of patient illness. It should also include a summary of events leading to admission, and a brief summary of the hospital course. Additional information on the patient’s care can be formatted in a problem- or system-based assessment and should be adapted to your internal workflow.

  • A summary statement or “one-liner”
  • Identification Statement, weight, allergies, code status
  • Events leading to admission: Surgery, Surgeon, Date, Intra-Op complications
  • Hospital course by systems, including:
    • Cardiac
    • Respiratory
    • Fluid, Electrolyte, Nutrition/GI
    • Neuro
    • Genetics
    • Scheduled Medications
    • Access/Vascular
    • Consultations
    • Social: Language, Support, Concerns

A – Action List

(To-do list, timeline, and ownership)

In an Action List, the off-going clinician provides key action items that need to be accomplished during the next shift.

  • This will specify actions to be completed during the shift which are distinct from the broader hospital plan and contingency plans.
  • What needs to be done?
  • When to do it/What time?
  • What to do about it?
  • Pending results/studies to follow up

S – Situation Awareness and Contingency Planning

(Know what’s going on, plan for what might happen)

The Situation Awareness and Contingency Planning element allow the off-going clinician to highlight potential situations that may arise with the patient’s care and how to address them. This provides the opportunity to develop and communicate solutions to problems before they happen.

Clear contingency plans will help to develop a shared mental model between the giver and receiver of potential problems that may occur; these should be structured in an “If, then” format. If caring for a patient who cannot receive visitors, then your situational awareness may include whether the patient’s family needs to be updated and at what interval or based on what criteria.

  • Provides the receiver with specific instructions for what might go wrong
  • List interventions that HAVE/HAVE NOT worked
  • Contingency Planning – Problem-solving before things go wrong:
  • “If this happens, then…”
  • Provides the receiver with specific instructions for what might go wrong
  • Ensures accepting team is prepared to anticipate changes in patient status and respond accordingly
  • Identify resources and chain of command
  • For stable patients: “
    • I don’t anticipate that anything will go wrong.”

S – Syntheses by Receiver

(Receiver summarizes what was heard, asks questions, restates key action/to-do items)

Synthesis by Receiver is a verbal statement from the receiver that tells the giver the receiver has a clear understanding of the handoff. A good synthesis is not a restating of the handoff, but rather is a brief, condensed and prioritized summary of the most important elements of the handoff. A good synthesis includes a brief summary of the action items and contingency plans.

  • The receiver should allow the person giving the handoff to get through the first 4 elements (IPAS) first without interruptions.
  • Opportunity for the receiver to ask questions, clarify and then synthesize what they heard
  • Brief re-statement/summary of essential information and written documentation
  • Demonstrates information is received and understood
  • The receiver may synthesize the facts differently
  • Keeps the receiver more engaged

Though handoff communication should always occur verbally, a written handoff tool that is structured in the I-PASS format to include these five elements should be used to align with the verbal process.

  • Documentation of Synthesis consists of:
    • The receiver’s notes from verbal handoff
    • EPIC/CERNER documentation
  • The receiver reads back their written notes taken during the report
  • Report giver and receiver review EPIC documentation and indicate I-PASS given
  • These supplement the verbal handoff
  • Helps receiver to follow report
  • Facilitates active participation by receiver
  • Provides more comprehensive and efficient information transfer


A recent publication documenting the implementation of I-PASS at a large academic medical center noted that assuring consistent and sustained adoption across all services is highly challenging. The I-PASS Institute was formed specifically to develop solutions that would overcome these challenges, and a robust body of data now support our early successes in doing so.

The I-PASS handoff methodology is a rigorously developed, evidence-based “bundle” of interventions. This bundle has been researched over a 10-year period, resulting in over 50 publications. A landmark 2014 New England Journal of Medicine publication (the leading medical journal in the world) found that implementing I-PASS in 9 hospitals led to a 30% reduction in medical errors that harmed patients.

Why the I-PASS Institute?

I-PASS is focused on improving patient safety by reducing medical errors caused by communication failures.

Our mission statement is to “Improve patient safety through the reduction of communication failures during patient handoffs and transitions in care”. With that being said, the I-PASS handoff method is considered a best-practice standard of patient care and is how we plan to turn our mission into a reality.

The components of the I-PASS program that help us achieve that are:

  • Training programs
  • Integration of the standard structure into computerized handoff tools within the electronic medical record
  • Structured observations of handoffs in the clinical workplace to facilitate quality improvement initiatives
  • Faculty and team development
  • Culture change campaigns to support adoption and sustainability

Through the use of our web-based tools and the expertise of our professional coaches, we seek to accelerate the adoption of I-PASS at hospitals in the U.S. and ultimately worldwide.

Together, our success can lead to increased patient safety and a reduction in healthcare costs.

PS – Schedule a virtual planning session with me, Marshall Burkhart, today! Click the button below to get started.

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