The development of the I-PASS mnemonic began after the Accreditation Council for Graduate Medical Education (ACGME) began requiring all resident training facilities to teach resident doctors handoff skills and monitor the quality of patient handoffs. The mnemonic stands for Illness severity, Patient summary, Action list, Situation awareness and contingency planning, and Synthesis by the receiver. 2 The I-PASS mnemonic is one option that can be used, and a few studies have indicated that a decrease in handoff related errors has occurred in many hospitals after I-PASS implementation.
Although the Joint Commission does not give specific data regarding handoff related errors, they do cite “communication errors”, including handoff errors as a contributing cause of two out of every three sentinel events in hospitals. 4 Many HROs use mnemonics when performing patient handoffs to standardize handoffs and reduce errors. The federal government suggested that organizations use principles from High Reliability Organizations (HROs), or organizations that consistently have high quality healthcare outcomes, to decrease medical errors.
The report prompted the United States (US) federal government to require healthcare facilities to reduce errors. In 1998, the Institute of Medicine published the report To Err is Human, which highlighted preventable deaths in healthcare settings caused by medical errors. 3 Frequent handoffs or handovers provide increased opportunities for handoff related errors to occur, which could lead to many more sentinel events. Some countries, such as those in Europe, refer to this interaction as a “ handover”. 1 A patient handoff occurs any time one healthcare provider transfers the care of a patient to another provider. 2 Sentinel events are serious, sometimes fatal, preventable adverse events that occur within a healthcare setting. 1 According to the Joint Commission, ineffective handoff communication leads to approximately 80% of serious medical errors and is the cause of two out of every three sentinel events. Handoff related errors are one of the leading causes of adverse events in hospitals.
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