Our study is unique in that it was resident driven. ![]() In our institution, one of our senior residents became interested in coordinating a multidisciplinary quality improvement (QI) project to improve the handoff process. 6 Finally, the project was applied to nine residency programs in the United States and Canada with a reduction in the overall medical error rate by 23% and a decrease in preventable adverse events by 30%. 5 Further study by this group in 2013 demonstrated a decrease in medical errors from 33.8% to 18.3% after the implementation of a multifaceted handoff program using IPASS. The IPASS mnemonic represents the key elements in a successful handoff process: I: Illness Severity P: Patient Summary A: Action Items S: Situation awareness and contingency planning S: Synthesis by receiver. developed the IPASS (illness severity, patient summary, action items, situation awareness and contingency planning, synthesis by receiver) mnemonic to help prevent error in verbal patient handoffs. Recent studies have reported success with implementation of a structured handoff system. The issue has come to the attention of the Accreditation Council for Graduate Medical Education (ACGME), which has mandated institutions to provide formal training in and faculty monitoring of patient handoff skills. 3 found that 59% of residents reported one or more patients had been harmed due to problematic handoffs 12% reported the harm had been major. ![]() Residents have recognized this gap in receiving and integrating information leads to negative patient outcomes. 2 in 2009 reported that while 75% of resident handoffs had agreement about the severity of the patient’s illness, there was a low agreement between giver and receiver about the most severe problem and the total problem list. It is well known that errors in communication account for nearly two-thirds of all sentinel events within a hospital. The importance of an effective patient handoff between resident physicians at shift change continues to gain exposure in the literature. Improving the communication of IPASS elements during resident handoffs: a resident-driven quality improvement project
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