I-PASS Implementation for the Reduction of Medical Error in Hospital Handoffs

Hanjaya Basuki, Andy Andrean, Tungki Pratama Umar

Faculty of Medicine, Sriwijaya University

Background : Medical error has been defined as an unintended act (either of omission or
commission) or one that does not achieve its intended outcome. One way to decrease
the number of the mistake is to upgrade our patient handoff system. Though there are
handoff procedures in indonesia, such procedure did not have a high perception to the
overall patient safety culture, as shown in the table below. Hospital handoff and
transitions only have a bit more than fifty percent positive perception.Other thing that
factor a handoff procedure error is communication failures (Starmer,2014). For this
case, we take a look at I-PASS, a mnemonic developed by Rosenbluth and West to
identify medical error that is used by Accreditation Council for Graduate Medical
Education (ACGME) of North America.

Material and Methods : We systematically, reviewed journals from database such as

NCBI, BMJ, JAMA, NEJM as well as government documents.

Result : According to Starmer (2014), from 10,740 patient admissions the

number of preventable adverse events were dropped by 30% from the preintervention
to the postintervention period (4.7 vs. 3.3 events per 100 admissions, P<0.001. The
rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events
per 100 admissions, P = 0.79). In the other hand, rate of non-harmful medical errors
were reduced by 21% following implementation of I-PASS. Overall reduction of
medical error were reported dropped by 23% from the preintervention to the
postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001)

Conclusion : I-PASS Handoff Bundle implementation was associated with,

reduction in overall error rates and preventable adverse events, improvements in verbal
and written handoff communications, and it is not recommended for patient who
require broader information and context. I-PASS is better used in condition where is
time is limited.

Keywords : I-PASS, Medical Error, Hospital Handoffs

Author:

1. Hanjaya Basuki

Email : hanjaya.basuki97@gmail.com

Phone : +6282362894684

2. Andy Andrean

Email : andreanandy12@gmail.com

Phone : +6281239652335

3. Tungki Pratama Umar

Email : tungkipratamaumar@gmail.com

Phone : +6285368708668