CONTRIBUTORS: Amy J. Starmer, MD, MPH,a,b Nancy D.

Spector, MD,c
Rajendu Srivastava, MD, MPH,d April D. Allen, MPA, MA,b,e Christopher P.
Landrigan, MD, MPH,b,f Theodore C. Sectish, MDb and the I-PASS Study
Group
a
Department of Pediatrics, Doernbecher Children’s Hospital, Oregon Health and
Science University, Portland, Oregon; bDivision of General Pediatrics,
Department of Medicine, Children’s Hospital Boston, and fDivision of Sleep
Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard
Medical School, Boston, Massachusetts; cSection of General Pediatrics, St.
Christopher’s Hospital for Children, Department of Pediatrics, Drexel University
College of Medicine, Philadelphia, Pennsylvania; dDepartment of Pediatrics,
Primary Children’s Medical Center, Salt Lake City, Utah; and eHeller School for
Social Policy and Management, Brandeis University, Waltham, Massachusetts.
The opinions and conclusions expressed herein are solely those of the authors
and should not be constructed as representing the opinions or policy of any
agency of the Federal Government.
Address correspondence to Amy J. Starmer, MD, MPH, Department of Pediatrics,
Doernbecher Children’s Hospital, Oregon Health and Science University, Mail
code: CDRCP, 707 SW Gaines St, Portland, OR 97239-2998. E-mail: starmer@ohsu.
edu
Accepted for publication Nov 22, 2011
doi:10.1542/peds.2011-2966

I-PASS, a Mnemonic to Standardize Verbal Handoffs

The first cohort of IIPE projects from institutions.1 The resident handoff bun- of the I-PASS mnemonic will be defined
2009 are beginning to realize some early dle includes 3 major elements: team in this article.
successes. We bring you this article in training by using focused TeamSTEPPS Mnemonics are memory aids. Effective
the spirit of sharing what works and communication strategies,2 implementa- mnemonics are catchy, symbolic, par-
what doesn’t. The lesson about the tion of a standardized template for simonious, utilitarian, and may conjure
importance of context is critical in the written or printed computerized up a visual image linked to a process or
adopting and adapting innovations to handoff document, and introduction of subject. In this report, we emphasize
your own learning environment. several evidence-based verbal handoff the importance of structured commu-
—Carol Carraccio, MD, MA processes, which are referred to by nication strategies to enhance patient
Section Editor using a novel verbal mnemonic. This safety, review literature pertinent to the
New duty hours standards have in- multisite collaborative education and handoff process, including the use of
creased the frequency of transitions in research project was launched with verbal mnemonics, and describe the
care or handoffs for resident physi- the support of the Initiative for In- creation of the I-PASS mnemonic, a core
cians. Because miscommunications are novation in Pediatric Education (IIPE) element of our resident handoff bundle.
a leading cause of adverse events in and the Pediatric Research in Inpa-
tient Settings (PRIS) network. The title Background
hospitals, optimizing the handoff pro-
cess is essential for patient safety. The I-PASS is an acronym that not only Communication errors are a contribut-
I-PASS Study aims to determine the denotes the title and purpose of our ing cause of approximately two-thirds
effectiveness of implementing a “resi- research study—IIPE-PRIS Accelerat- of sentinel events,3 over half of which
dent handoff bundle” to standardize ing Safe Sign-outs—but also serves as involve handoff failures.4 In health
inpatient transitions in care and de- the verbal mnemonic for the standard- care, the magnitude of the patient
crease medical errors in 10 pediatric ized handoff itself. Individual elements safety epidemic first became widely

PEDIATRICS Volume 129, Number 2, February 2012 201

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recognized with the publication of To days) and adverse drug events (from including regular faculty and chief res-
Err Is Human in 1999, which concluded 30 to 18 per 1000 patient days).9 ident observations and feedback re-
that medical errors cause up to 98 000 SBAR was developed to facilitate the garding the verbal handoff process.
preventable deaths annually in the efficient transmission of information. It However, we found that a majority of
United States.5 Subsequently, calls for is most effective when time is limited verbal handoffs did not adhere to the
action emerged from the federal gov- and a quick decision is needed, as this structure of the SIGNOUT mnemonic.
ernment and many private and pro- tool is suited to situations when a brief As part of the process for curriculum
fessional organizations, including the summary is sufficient and fewer than development for the I-PASS study, we
recommendation that principles from 5 key points need to be communicated. reflected on the successes and chal-
High Reliability Organizations (HROs) Further, this mnemonic should be used lenges of SIGNOUT, and considered use
be applied to the health care system. as a situational briefing tool, as intended, of the mnemonic, IPASSTHEBATON from
HROs are organizations in high-risk, and is appropriate for use across hi- TeamSTEPPS.13 Feedback from chief
high-impact industries that consis- erarchical boundaries.10 Although use residents who had been involved in the
tently achieve high quality outcomes of SBAR has been extended to handoffs pilot curriculum, however, expressed
despite experiencing many unexpected of patient care at change of shift or the need for a mnemonic that was
events where the potential for error is patient location, there are limitations shorter, easier to remember, and had
very high.6 These organizations em- in its applicability, particularly in sit- discrete elements without overlap.
ploy team training and reliability sci- uations that include transmission of in- They felt strongly that elements of the
ence to improve their performance, formation about complex patients who mnemonic needed to be fully integrated
the roots of which arose from the require broader information and context.
into computerized handoff tools.
military and civilian aviation commu-
Modeling the process used to design
nities. Programs such as Crew Re- Development of the I-PASS
the original SBAR mnemonic, we (Drs
source Management have led to major Mnemonic
Starmer, Spector, Landrigan, and Sect-
advances in team training and may Given the limitations of SBAR, alterna- ish) conducted a brainstorming session
result in dramatic improvements in tive mnemonics have been developed, and identified the essential elements of
fatalities, accident related costs, and implemented, and tested for use in a verbal handoff. We focused on ele-
human factor based mishaps. handoffs of care. A recent systematic ments that pilot study faculty observers
A specific application of HRO principles review of published handoff mnemon- noted were most commonly absent
is the use of explicit verbal mnemonics ics identified 46 articles describing from resident handoffs (illness severity
to standardize communication. One of 24 different handoff mnemonics.11 Most assessment, contingency planning, and
the most commonly used communication have not been rigorously studied, how- read-back by the receiving resident)
tools, SBAR, an acronym for “situation, ever, and descriptions of their deriva- and incorporated best practices for
background, assessment, recommenda- tion are lacking. A notable exception verbal handoffs from our review of
tion,” was developed by Doug Bonacum, includes an article describing the use existing literature.
vice president of Kaiser Permanente and of the SIGNOUT mnemonic, which was
shown to increase the consistency and The results of this session led to the
former safety officer on a nuclear sub-
confidence with which residents perform development of a novel mnemonic, I-PASS
marine.7 During a patient safety
verbal sign-outs, as compared with an (Fig 1), which serves as the cornerstone
workgroup meeting, Bonacum de-
implicit, informally structured process.12 for the resident handoff bundle that
scribed expectations when handing off
is currently being implemented and
a situation to an officer on deck. These Drawing from the apparent evidence-
tested in the I-PASS study.
key concepts were translated into core based success of the SIGNOUT mnemo-
elements of the SBAR mnemonic. Suc- nic, we included the SIGNOUT mnemonic The I-PASS mnemonic provides a frame-
cess of a pilot study investigating the in a pilot resident handoff bundle work for the patient handoff process as
use of SBAR as a communication tool intervention study at the Children’s follows:
led to rapid spread across hospitals Hospital Boston that preceded the I: Illness severity
nationwide and studies examining its ongoing multicenter I-PASS study. P: Patient summary
effectiveness.8 Implementation of SBAR Resident input was a key factor in this A: Action list
in 1 hospital was associated with sub- selection. Efforts were made to re- S: Situation awareness and contin-
stantial drops in the rates of adverse inforce use of the mnemonic dur- gency planning
events (from 90 to 40 per 1000 patient ing the postintervention study period, S: Synthesis by receiver

202 STARMER et al
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 PEDIATRICS PERSPECTIVES

Conclusions and the Agency for Health Care Research

and Quality, grant 1K12HS019456-01.
The novel mnemonic, I-PASS, was de-
Developed with input from the IIPE
veloped from best handoff practices
and the PRIS Network.
cited in the literature, resident feed-
back from a pilot study, and obser- IIPE is the Initiative for Innovation in Pe-
vations made by faculty of the handoff diatric Education and is the entity that
process. Structured communication, recognizes innovative educational pro-
especially at the time of transitions in posals for pediatric residency training
care, is essential to promote patient programs. More can be found on the
safety. The multisite I-PASS study will Web site, www.innovatepedsgme.org.
test the effectiveness of the resident PRIS is a collaborative hospitalist re-
handoff bundle, including the I-PASS search network sponsored by the
mnemonic, on medical errors in 10 American Academy of Pediatrics, the Ac-
pediatric institutions. Lessons learned ademic Pediatric Association, the Soci-
may apply to other settings where the ety of Hospital Medicine, and the Child
opportunities to improve the handoff Health Corporation of America. Details
FIGURE 1 process remain a challenge. are available at http://www.prisnetwork.
Elements of the I-PASS mnemonic. org.
ACKNOWLEDGMENTS Members of the I-PASS Study Group in-
An example of a verbal I-PASS handoff This project was supported with a grant clude coinvestigators from the follow-
communication is provided in Fig 2. from the US Department of Health and ing institutions as follows: Children’s
As we began implementing the I-PASS Human Services, Office of the Assistant Hospital Boston (primary site): April
mnemonic, we received widespread in- Secretary for Planning and Evaluation, D. Allen, MPA, MA, Angela Feraco, MD,
terest in it from other providers in our grant 1R18AE000023-01. Additionally Christopher P. Landrigan, MD, MPH,
study institutions, including physicians Drs Landrigan and Srivastava are sup- Theodore C. Sectish, MD; Brigham and
from other specialties and nurses. We ported in part by the Child Health Cor- Women’s Hospital (data coordinating
believe that it can readily be adapted for poration of America for their work on center): Carol Keohane, RN, Stuart Lip-
use beyond pediatrics. Specifically, the the PRIS Research Network Executive sitz, PhD, Jeffrey Rothschild, MD, MPH;
patient summary element is easily adap- Council. Dr Starmer is supported in part Cincinnati Children’s Hospital Medical
ted to include specific information ele- by an institutional K12 award from Center: Javier Gonzalez del Rey, MD,
ments that are key for each provider type. Oregon Health and Science University Med, Jennifer O’Toole, MD, Lauren Solan,

FIGURE 2
Example of a verbal handoff by using the I-PASS mnemonic.

PEDIATRICS Volume 129, Number 2, February 2012 203

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MD; Doernbecher Children’s Hospital/ Francisco, Benioff Children’s Hospital: 6. McKeon LM, Oswaks JD, Cunningham PD.
Oregon Health and Science University: Glenn Rosenbluth, MD, Daniel C. West, Safeguarding patients: complexity science,
high reliability organizations, and implications
Megan Aylor, MD, Gregory Blaschke, MD. Dorene Balmer, PhD, RD and Alan for team training in healthcare. Clin Nurse
MD, MPH, Cynthia L. Ferrell, MD, MSEd, Schwartz, PhD, serve the I-PASS Study Spec. 2006;20(6):298–304, quiz 305–306
Benjamin D. Hoffman, MD, Amy J. Group as part of the IIPE Research 7. Denham CR. SBAR for patients. J Patient
Starmer, MD, MPH, Windy Stevenson, Support Team. Karen M. Wilson, MD, Saf. 2008;4(1):38–48
MD, Tamara Wagner, MD; Hospital for MPH, serves the I-PASS Study Group 8. McFerran S, Nunes J, Pucci D, Zuniga A.
as part of the PRIS advisory board. Perinatal Patient Safety Project: a multi-
Sick Children/University of Toronto: Zia
center approach to improve performance
Bismilla, MD, Maitreya Coffey, MD, Sanjay reliability at Kaiser Permanente. J Perinat
Mahant, MD, MSc, Anne Matlow, MD; Neonatal Nurs. 2005;19(1):37–45
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FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

204 STARMER et al
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 I-PASS, a Mnemonic to Standardize Verbal Handoffs
Amy J. Starmer, Nancy D. Spector, Rajendu Srivastava, April D. Allen, Christopher
P. Landrigan, Theodore C. Sectish and the I-PASS Study Group
Pediatrics 2012;129;201; originally published online January 9, 2012;
DOI: 10.1542/peds.2011-2966
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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 I-PASS, a Mnemonic to Standardize Verbal Handoffs
Amy J. Starmer, Nancy D. Spector, Rajendu Srivastava, April D. Allen, Christopher
P. Landrigan, Theodore C. Sectish and the I-PASS Study Group
Pediatrics 2012;129;201; originally published online January 9, 2012;
DOI: 10.1542/peds.2011-2966

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/129/2/201.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from by guest on May 24, 2016