Johns Hopkins Children’s Center Uses AHRQ-Funded I-PASS Tool to Boost Patient Safety

Patient Safety
April 2019

Pediatric residents at Johns Hopkins Children’s Center in Baltimore, MD, changed the way they handed off patients between shift changes by closely adhering—sometimes by as much as 100 percent—to the AHRQ-supported and proven care transition tool called I-PASS. I-PASS is a process to enhance communication when coordinating patients’ transfer of care during medical staff shift changes, improving patient care and safety.  

“I-PASS is designed to improve hospital communication and reduce errors by providing a standardized structure for medical staff to follow when communicating about a patient’s condition,” said Thuy L. Ngo, D.O., M.Ed., an Assistant Professor of Pediatrics at Johns Hopkins.

“Miscommunication is a leading cause of adverse events in hospital patients’ care, which is why optimizing the patient handoff process by using a standardized communications process helps to promote patient safety. This is especially important during shift changes,” she added.

Dr. Ngo noted that the I-PASS technique also has improved coordination of patient care. “With the very strenuous schedules of residents, there are ample opportunities for errors,” she said. “But by having a standard template for communication that offers a synchronized handoff of patients, those on the next shift are better able to understand and prepare for each patient’s needs for the next 14 to 16 hours.”

I-PASS stands for illness severity, patient summary, action list, situation awareness, and synthesis by the receiver, all aspects of a patient’s condition which are conveyed to the next shift. It was tested by both academic and community hospitals that varied in size and patient population and represented internal medicine, pediatric, and other medical specialties.

The I-PASS process has been well received by the Johns Hopkins pediatric residents, according to Helen Hughes, M.D., M.P.H, an Assistant Professor of Pediatrics at the university. “The majority of our residents—over 90 percent—recognized that I-PASS is effective in enhancing patient safety. They’ve been excited about using this technique because they can see that it enhances their understanding and leads to greater quality improvement,” she said.

I-PASS is used throughout the children’s center for inpatient and emergency department care provided by pediatric residents. Attending physicians and nurses have begun incorporating I-PASS into their communication training as well. Other departments, such as anesthesia and plastic surgery, are also interested in incorporating I-PASS in their residency programs, Dr. Ngo said.

John Hopkins Children’s Center was one of 32 hospitals that tested the I-PASS technique as part of an I-PASS Mentored Implementation Project funded by AHRQ. Initially, the goal was to have the Johns Hopkins pediatric residents adhere to 75 percent of the components of the I-PASS process. But by March 2017, residents monitored in the test study were handing off their patients to the next shift with 100 percent adherence to I-PASS as determined by faculty observations of their handoffs.

Each participating hospital was paired with a mentorship team of I-PASS experts who made site visits, provided monthly coaching, and reinforced the communications skills training, according to Amy Starmer, M.D., M.P.H., a physician at Boston Children’s Hospital and Harvard Medical School, who was the project leader of the I-PASS Mentored Implementation project. “Future studies will help us to understand ways in which the program can be successfully adapted for a wide variety of providers and handoff types,” she said.

Impact Case Study Identifier: 
AHRQ Product(s): I-PASS Mentored Implementation Project
Topics(s): Care Coordination, Children/Adolescents, Emergency Department, Outcomes, Patient Safety, Quality of Care
Geographic Location: Maryland
Implementer: Johns Hopkins Children’s Center
Date: 04/10/2019
Page last reviewed April 2019
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