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 StudyGroupaDepartment of Pediatrics, Doernbecher Children’s Hospital, Oregon Health andScience University, Portland, Oregon; bDivision of General Pediatrics,Department of Medicine, Children’s Hospital Boston, and fDivision of SleepMedicine, Department of Medicine, Brigham and Women’s Hospital, HarvardMedical School, Boston, Massachusetts; cSection of General Pediatrics, St.Christopher’s Hospital for Children, Department of Pediatrics, Drexel UniversityCollege of Medicine, Philadelphia, Pennsylvania; dDepartment of Pediatrics,Primary Children’s Medical Center, Salt Lake City, Utah; and eHeller School forSocial Policy and Management, Brandeis University, Waltham, Massachusetts.

The opinions and conclusions expressed herein are solely those of the authorsand should not be constructed as representing the opinions or policy of anyagency of the Federal Government.

Address correspondence to Amy J. Starmer, MD, MPH, Department of Pediatrics,Doernbecher Children’s Hospital, Oregon Health and Science University, Mailcode: 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 HandoffsThe first cohort of IIPE projects from2009 are beginning to realize some earlysuccesses. We bring you this article inthe spirit of sharing what works andwhat doesn’t. The lesson about theimportance of context is critical inadopting and adapting innovations toyour own learning environment.

—Carol Carraccio, MD, MA

Section Editor

New duty hours standards have in-creased the frequency of transitions incare or handoffs for resident physi-cians. Because miscommunications area leading cause of adverse events inhospitals, optimizing the handoff pro-cess is essential for patient safety. TheI-PASS Study aims to determine theeffectiveness of implementing a “resi-dent handoff bundle” to standardizeinpatient transitions in care and de-crease medical errors in 10 pediatric

institutions.1 The resident handoff bun-dle includes 3 major elements: teamtraining by using focused TeamSTEPPScommunication strategies,2 implementa-tion of a standardized template forthe written or printed computerizedhandoff document, and introduction ofseveral evidence-based verbal handoffprocesses, which are referred to byusing a novel verbal mnemonic. Thismultisite collaborative education andresearch project was launched withthe support of the Initiative for In-novation in Pediatric Education (IIPE)and the Pediatric Research in Inpa-tient Settings (PRIS) network. The titleI-PASS is an acronym that not onlydenotes the title and purpose of ourresearch study—IIPE-PRIS Accelerat-ing Safe Sign-outs—but also serves asthe verbal mnemonic for the standard-ized handoff itself. Individual elements

of the I-PASS mnemonic will be definedin this article.

Mnemonics are memory aids. Effectivemnemonics are catchy, symbolic, par-simonious, utilitarian, and may conjureup a visual image linked to a process orsubject. In this report, we emphasizethe importance of structured commu-nication strategies to enhance patientsafety, review literature pertinent to thehandoff process, including the use ofverbal mnemonics, and describe thecreation of the I-PASS mnemonic, a coreelement of our resident handoff bundle.

Background

Communication errors are a contribut-ing cause of approximately two-thirdsof sentinel events,3 over half of whichinvolve handoff failures.4 In healthcare, the magnitude of the patientsafety epidemic first became widely

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recognized with the publication of ToErr Is Human in 1999, which concludedthat medical errors cause up to 98 000preventable deaths annually in theUnited States.5 Subsequently, calls foraction emerged from the federal gov-ernment and many private and pro-fessional organizations, including therecommendation that principles fromHigh Reliability Organizations (HROs)be applied to the health care system.

HROs are organizations in high-risk,high-impact industries that consis-tently achieve high quality outcomesdespite experiencing many unexpectedevents where the potential for error isvery high.6 These organizations em-ploy team training and reliability sci-ence to improve their performance,the roots of which arose from themilitary and civilian aviation commu-nities. Programs such as Crew Re-source Management have led to majoradvances in team training and mayresult in dramatic improvements infatalities, accident related costs, andhuman factor based mishaps.

A specific application of HRO principlesis the use of explicit verbal mnemonicsto standardize communication. One ofthe most commonly used communicationtools, SBAR, an acronym for “situation,background, assessment, recommenda-tion,” was developed by Doug Bonacum,vice president of Kaiser Permanente andformer safety officer on a nuclear sub-marine.7 During a patient safetyworkgroup meeting, Bonacum de-scribed expectations when handing offa situation to an officer on deck. Thesekey concepts were translated into coreelements of the SBAR mnemonic. Suc-cess of a pilot study investigating theuse of SBAR as a communication toolled to rapid spread across hospitalsnationwide and studies examining itseffectiveness.8 Implementation of SBARin 1 hospital was associated with sub-stantial drops in the rates of adverseevents (from 90 to 40 per 1000 patient

days) and adverse drug events (from30 to 18 per 1000 patient days).9

SBAR was developed to facilitate theefficient transmission of information. Itis most effective when time is limitedand a quick decision is needed, as thistool is suited to situations when a briefsummary is sufficient and fewer than5 key points need to be communicated.Further, this mnemonic should be usedas a situational briefing tool, as intended,and is appropriate for use across hi-erarchical boundaries.10 Although useof SBAR has been extended to handoffsof patient care at change of shift orpatient location, there are limitationsin its applicability, particularly in sit-uations that include transmission of in-formation about complex patients whorequire broader information and context.

Development of the I-PASSMnemonic

Given the limitations of SBAR, alterna-tive mnemonics have been developed,implemented, and tested for use inhandoffs of care. A recent systematicreview of published handoff mnemon-ics identified 46 articles describing24 different handoff mnemonics.11 Mosthave not been rigorously studied, how-ever, and descriptions of their deriva-tion are lacking. A notable exceptionincludes an article describing the useof the SIGNOUT mnemonic, which wasshown to increase the consistency andconfidence with which residents performverbal sign-outs, as compared with animplicit, informally structured process.12

Drawing from the apparent evidence-based success of the SIGNOUT mnemo-nic, we included the SIGNOUT mnemonicin a pilot resident handoff bundleintervention study at the Children’sHospital Boston that preceded theongoing multicenter I-PASS study.Resident input was a key factor in thisselection. Efforts were made to re-inforce use of the mnemonic dur-ing the postintervention study period,

including regular faculty and chief res-ident observations and feedback re-garding the verbal handoff process.However, we found that a majority ofverbal handoffs did not adhere to thestructure of the SIGNOUT mnemonic.

As part of the process for curriculumdevelopment for the I-PASS study, wereflected on the successes and chal-lenges of SIGNOUT, and considered useof the mnemonic, IPASSTHEBATON fromTeamSTEPPS.13 Feedback from chiefresidents who had been involved in thepilot curriculum, however, expressedthe need for a mnemonic that wasshorter, easier to remember, and haddiscrete elements without overlap.They felt strongly that elements of themnemonic needed to be fully integratedinto computerized handoff tools.

Modeling the process used to designthe original SBAR mnemonic, we (DrsStarmer, Spector, Landrigan, and Sect-ish) conducted a brainstorming sessionand identified the essential elements ofa verbal handoff. We focused on ele-ments that pilot study faculty observersnoted were most commonly absentfrom resident handoffs (illness severityassessment, contingency planning, andread-back by the receiving resident)and incorporated best practices forverbal handoffs from our review ofexisting literature.

The results of this session led to thedevelopment of a novel mnemonic, I-PASS(Fig 1), which serves as the cornerstonefor the resident handoff bundle thatis currently being implemented andtested in the I-PASS study.

The I-PASS mnemonic provides a frame-work for the patient handoff process asfollows:

I: Illness severityP: Patient summaryA: Action listS: Situation awareness and contin-gency planningS: Synthesis by receiver

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An example of a verbal I-PASS handoffcommunication is provided in Fig 2.

As we began implementing the I-PASSmnemonic, we received widespread in-terest in it from other providers in ourstudy institutions, including physiciansfrom other specialties and nurses. Webelieve that it can readily be adapted foruse beyond pediatrics. Specifically, thepatient summary element is easily adap-ted to include specific information ele-ments that are key for each provider type.

Conclusions

The novel mnemonic, I-PASS, was de-veloped from best handoff practicescited in the literature, resident feed-back from a pilot study, and obser-vations made by faculty of the handoffprocess. Structured communication,especially at the time of transitions incare, is essential to promote patientsafety. The multisite I-PASS study willtest the effectiveness of the residenthandoff bundle, including the I-PASSmnemonic, on medical errors in 10pediatric institutions. Lessons learnedmay apply to other settings where theopportunities to improve the handoffprocess remain a challenge.

ACKNOWLEDGMENTSThis project was supported with a grantfrom the US Department of Health andHuman Services, Office of the AssistantSecretary for Planning and Evaluation,grant 1R18AE000023-01. AdditionallyDrs Landrigan and Srivastava are sup-ported in part by the Child Health Cor-poration of America for their work onthe PRIS Research Network ExecutiveCouncil. Dr Starmer is supported in partby an institutional K12 award fromOregon Health and Science University

and the Agency for Health Care Researchand Quality, grant 1K12HS019456-01.Developed with input from the IIPEand the PRIS Network.

IIPE is the Initiative for Innovation in Pe-diatric Education and is the entity thatrecognizes innovative educational pro-posals for pediatric residency trainingprograms. More can be found on theWeb site, www.innovatepedsgme.org.

PRIS is a collaborative hospitalist re-search network sponsored by theAmerican Academy of Pediatrics, the Ac-ademic Pediatric Association, the Soci-ety of Hospital Medicine, and the ChildHealth Corporation of America. Detailsare available at http://www.prisnetwork.org.

Members of the I-PASS Study Group in-clude coinvestigators from the follow-ing institutions as follows: Children’sHospital Boston (primary site): AprilD. Allen, MPA, MA, Angela Feraco, MD,Christopher P. Landrigan, MD, MPH,Theodore C. Sectish, MD; Brigham andWomen’s Hospital (data coordinatingcenter): Carol Keohane, RN, Stuart Lip-sitz, PhD, Jeffrey Rothschild, MD, MPH;Cincinnati Children’s Hospital MedicalCenter: Javier Gonzalez del Rey, MD,Med, Jennifer O’Toole, MD, Lauren Solan,

FIGURE 1Elements of the I-PASS mnemonic.

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

PEDIATRICS PERSPECTIVES

PEDIATRICS Volume 129, Number 2, February 2012 203by guest on May 24, 2016Downloaded from

MD; Doernbecher Children’s Hospital/Oregon Health and Science University:Megan Aylor, MD, Gregory Blaschke,MD, MPH, Cynthia L. Ferrell, MD, MSEd,Benjamin D. Hoffman, MD, Amy J.Starmer, MD, MPH, Windy Stevenson,MD, Tamara Wagner, MD; Hospital forSick Children/University of Toronto: ZiaBismilla, MD, Maitreya Coffey, MD, SanjayMahant, MD, MSc, Anne Matlow, MD;Lucile Packard Children’s Hospital/Stanford University: Lauren Destino,MD, Jennifer Everhart, MD, MadelynKahana, MD, Shilpa J. Patel, MD; Na-tional Capital Consortium: JenniferHepps, MD, Joseph O. Lopreiato, MD,MPH, Clifton E. Yu, MD; Primary Children’sMedical Center/Intermountain HealthCare: James F. Bale, Jr., MD, RajenduSrivastava, MD, MPH, Adam Steven-son, MD; St. Louis Children’s Hospital/Washington University: KathleenBerchelmann, MD, F. Sessions Cole, MD,Christine Hrach, MD, Kyle S. Schulz, MD,Michael Turmelle, MD, Andrew White,MD; St. Christopher’s Hospital for Chil-dren: Sharon Calaman, MD, Bronwyn D.Carlson, MD, Matthew B. McDonald III,MD, Robert S. McGregor, MD, VahidehNilforoshan, MD, Nancy D. Spector,MD; and University of California, San

Francisco, Benioff Children’s Hospital:Glenn Rosenbluth, MD, Daniel C. West,MD. Dorene Balmer, PhD, RD and AlanSchwartz, PhD, serve the I-PASS StudyGroup as part of the IIPE ResearchSupport Team. Karen M. Wilson, MD,MPH, serves the I-PASS Study Groupas part of the PRIS advisory board.

REFERENCES1. Sectish TC, Starmer AJ, Landrigan CP,

Spector ND; I-PASS Study Group. Establish-ing a multisite education and researchproject requires leadership, expertise,collaboration, and an important aim.Pediatrics. 2010;126(4):619–622

2. US Department of Health and HumanServices, Agency for Healthcare Researchand Quality. TeamSTEPPS home page.Available at: http://teamstepps.ahrq.gov/.Accessed September 29, 2011

3. The Joint Commission. Sentinel event sta-tistics data: root causes by event type.Available at: www.jointcommission.org/Sentinel_Event_Statistics/. Accessed Sep-tember 27, 2011

4. The Joint Commission. Improving hand-off communications: meeting nationalpatient safety goal 2E. Joint CommissionPerspectives on Patient Safety. 2006;6(8):9–15

5. Institute of Medicine. To Err Is Human: Build-ing a Safer Health System. Washington, DC:National Academy Press; 1999

6. McKeon LM, Oswaks JD, Cunningham PD.Safeguarding patients: complexity science,high reliability organizations, and implicationsfor team training in healthcare. Clin NurseSpec. 2006;20(6):298–304, quiz 305–306

7. Denham CR. SBAR for patients. J PatientSaf. 2008;4(1):38–48

8. McFerran S, Nunes J, Pucci D, Zuniga A.Perinatal Patient Safety Project: a multi-center approach to improve performancereliability at Kaiser Permanente. J PerinatNeonatal Nurs. 2005;19(1):37–45

9. Haig KM, Sutton S, Whittington J. SBAR:a shared mental model for improving com-munication between clinicians. Jt Comm JQual Patient Saf. 2006;32(3):167–175

10. Monroe M. SBAR: A structured human fac-tors communication technique. HealthBeat. Des Plaines, IL: American Society ofSafety Engineers. Available at: www.asse.org/practicespecialties/healthcare/docs/HealthBeat_Newsletter_Spring2006%20for%20Web.pdf. Accessed September27, 2011

11. Riesenberg LA, Leitzsch J, Little BW. System-atic review of handoff mnemonics literature.Am J Med Qual. 2009;24(3):196–204

12. Horwitz LI, Moin T, Green ML. Developmentand implementation of an oral sign-outskills curriculum. J Gen Intern Med. 2007;22(10):1470–1474

13. US Department of Health and Human Serv-ices, Agency for Healthcare Research andQuality. Pocket guide: TeamSTEPPS. Availableat: www.ahrq.gov/teamsteppstools/instructor/essentials/pocketguide.htm#passbaton.Accessed September 28, 2011

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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