Patient handoff pilot reduces medical errors by 40 percent

Standardizing and improving the way that patient care is “handed off” during hospital shift changes can reduce medical errors by as much as 40 percent, according to a press release from Boston Children’s Hospital.

The press release states that a new patient safety initiative,  I-PASS, has several components, including an easy-to-remember mnemonic to ensure that key information is imparted in each handoff  (I– Illness severity; P – Patient summary; A – Action list for the next team;S - Situation awareness and contingency plans; S – Synthesis and “read-back” of the information), creation of a printed handoff document that can be integrated into the patient’s electronic medical record, direct, structured observation of handoffs by senior physicians with feedback, and medical team training.

Key findings from Children’s Hospital after implementing the program for three months:

  • There was a 40 percent reduction in medical errors after implementation (from 32 percent of admissions to 19 percent).  
  • Doctors spent more time with patients (225 minutes per 24-hour period, versus 122 minutes before implementation of the handoff program) and less time at the computer (370 vs. 408 minutes per 24 hours).
  • Handoffs were about twice as likely to occur in a private or quiet location.

(Sources: Children’s Hospital Press Release,, April 29, 2012; The Advisory Board Daily Briefing,, May 2, 2012)