I-PASS System Reduces Medical Errors, Study Says

Countless medical errors committed each year by healthcare providers jeopardize patient safety and claim lives. About 80 percent of the most serious types of medical errors committed by U.S. healthcare providers stem from miscommunication among providers, most notably during patient handoffs.

Now, a recent study demonstrates how a new system can reduce hospital medical error rates by as much as 30 percent.

I-PASS system

It is likely that patient safety advocates will strongly embrace the widespread use of the I-PASS system for reducing hospital medical error rates. I-PASS is an acronym and a useful mnemonic for illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver. Essentially, it’s a group of communication and training strategies that healthcare providers can use when transferring patients to the care of another healthcare provider. Providers can use this bundle of tools to prevent medical errors due to miscommunication.

For example, providers can communicate with each other about the patient’s illness severity, which may be classified as “stable,” “unstable,” or “watcher,” in other words, the patient requires monitoring. The patient summary is a written or verbal synopsis of the patient’s general information (i.e. age), recent medical history and diagnosis, and current treatment regimen. The action list informs the provider who is receiving the patient what needs to be done in the immediate future. For example, the provider might need to ensure that the patient’s vitals are still stable.

Situation awareness and contingency planning alert the healthcare provider as to what may happen with the patient and what the provider’s response should be. For example, if the patient’s respiratory condition worsens, the receiving provider should order a chest radiograph to check for an effusion. Lastly, synthesis by receiver refers to the receiving healthcare provider’s repetition of the information to ensure accuracy.

Study results

Most recently, the system was evaluated in a study published in the November 6, 2014 issue of the New England Journal of Medicine. This new study evaluated the use of the I-PASS system at nine hospitals scattered throughout the U.S. The researchers evaluated medical errors and patient handoffs by hospital residents during multiple time periods. The data was analyzed during a six-month period before the implementation of the I-PASS system; during the six-month interventional period in which hospital residents began to learn the I-PASS system; and during the subsequent six months. During all of those phases, the number of patient admissions studied totaled 10,740.

The results of the study demonstrate that the implementation of the I-PASS system reduced hospital medical error rates by 23 percent. The starting rate of medical errors was 24.5 per 100 admissions and the ending rate of errors was 18.8 errors per 100 admissions. Encouragingly, the rate of preventable errors was reduced by an impressive 30 percent. It had been 4.7 medical errors per 100 admissions; the I-PASS system appeared to reduce preventable errors to 3.3 per 100 admissions.

Furthermore, the researchers noted that the use of the I-PASS system did not increase the amount of time hospital residents spent on patient handoffs, which means that it does not adversely affect the amount of time providers spend with patients.