Miscommunication plays a role in approximately 80 percent of the most serious
medical errors that occur in U.S. hospitals, such as delays in diagnosis,
preventable surgical complications, and medication overdoses. Many of
the mistakes occur when patients are handed off from one healthcare provider
To reduce the risk of miscommunication, hospitals are working to develop
new procedures, particularly during shift changes. As detailed in a recent
study, some have shown to be very promising.
When implemented in nine hospitals, the I-PASS system reduced injuries
from medical errors by 30 percent. The mnemonic is intended to help health-care
workers remember steps for properly communicating important patient information
during a shift change. I-PASS stands for
situational awareness and contingency planning, and
synthesis by receiver.
“Miscommunications and handoff errors are two of the most significant
causes of medical errors in hospitals in the U.S.,” senior author
Christopher Landrigan, MD, MPH, from Boston Children’s Division
of General Pediatrics, stated. “This is the first multicenter handoff
improvement program that has been found to reduce injuries due to medical
In addition to reducing medical mistakes, the study found that using the
I-PASS system did not add time to patient handoffs or decrease time spent
at other patient tasks. In addition, the researchers noted significant
improvements in residents’ verbal and written communications at
every hospital studied.
As San Diego medical malpractice lawyers, we are encouraged by the results
of the study. We are hopeful that similar systems can be implemented across
the country to reduce the risk of preventable medical errors.