42. I-PASS Explained: Improving Clinical Handoffs from Philadelphia

What happens when a patient’s care is transferred from one clinician to another? In this episode, UC Davis medical students Ian Marquez, Nicholas Le, and Marco Oliveras explore I-PASS, a structured approach to safer, clearer clinical handoffs. They speak with Daniel West who explains how I-PASS helps healthcare teams build a shared mental model and communicate reliably under pressure. Their conversation examines communication failures, culture change, and the future of safer, more reliable healthcare. Discover how better clinical handoffs are a critical patient safety intervention.

References

• DeRienzo CM, Frush K, Barfield ME, et al. Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements. Acad Med. 2012;87(4):403-410.
• Franco Vega MC, Ait Aiss M, Smith M, et al. Improving handoff with the implementation of I-PASS at a tertiary oncology hospital. BMJ Open Qual. 2023;12(4):e002481.
• Huber A, Moyano B, Blondon K. Secondary analysis of hand-offs in internal medicine using the I-PASS mnemonic. BMC Med Educ. 2024;24(1):1046. 
• Khan A, Spector ND, Baird JD, et al. Patient safety after implementation of a coproduced family centered communication programme: multicenter before and after intervention study. BMJ. 2018;363:k4764.
• Shahian DM. I-PASS handover system: a decade of evidence demands action. BMJ Qual Saf. 2021;30(10):769-774.
• Sheng J, Manjunath S, Michael M, et al. Integrating handover curricula in medical school. Clin Teach. 2020;17(6):661-668.
• Soares DRA, Rodrigues D, Carmona F. Implementation of a standardized handoff system (I-PASS) in a tertiary care pediatric hospital. Rev Paul Pediatr. 2023;41:e2022123.
• Starmer AJ, Spector ND, O'Toole JK, et al. Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. J Hosp Med. 2023;18(1):5-14.
• Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC; I-PASS Study Group. I-PASS, a mnemonic to standardize verbal handoffs. Pediatrics. 2012;129(2):201-204.
• Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):1803-1812.