Original Article

Journal of Patient Safety and Risk

Management
Improved handoff quality and reduction 0(0) 1–8
! The Author(s) 2020
in adverse events following Article reuse guidelines:
sagepub.com/journals-permissions
implementation of a Spanish-language DOI: 10.1177/2516043520961708
journals.sagepub.com/home/cri

version of the I-PASS bundle for pediatric

hospitalized patients in Argentina

Facundo Jorro Bar
on1 , Celina Diaz Pumara2,

Mar
ıa Agustina Janer Tittarelli2, Agustina Raimondo2,
Marcela Urtasun2 and Lucila Valentini2

Abstract
Introduction: communication errors between medical personnel are known to be a leading source of adverse events
(AEs). The implementation of teamwork training together with the use of a standardized handoff bundle has previously
shown to reduce the number of AEs. However, the applicability of this program in spanish-speaker countries remains unclear.
Objective: to assess whether the exploratory implementation of I-PASS bundle in an Argentine pediatric hospital is
associated with a reduction in the rate of AEs.
Methods: Design: an exploratory, uncontrolled, pre-post study.
Population and sample: medical records (MR), medical prescriptions, and physician reports were reviewed in two clinical
wards of the "Hospital General de Ni~nos Pedro de Elizalde".
Intervention: I-PASS Spanish version, an standardized handoff bundle consists in: a mnemonics, an introductory work-
shop, a written handoff tool, simulation sessions, and structured observations with feedback.
Results: we reviewed 264 MR. Preventable AEs decreased by 62.8% between pre-intervention and post-intervention
period (12.1 vs 4.5 AEs/100 admissions; IC95: 0.010; 0.142; [p ¼ 0.025]). Adherence to the use of quality handoff key
elements increased significantly, from 25% to 61% in post-intervention period (p ¼ 0.0001). Handoff duration did not
change significantly (5.5  0.2 vs 5.3  0.3 minutes per patient [p ¼ 0.59]).
Conclusion: Implementation of an I-PASS Spanish version was associated with a significant reduction in the rate of AEs
and with improvements in handoff quality; without changes in duration.

Keywords
Handoff, patient safety, communication, hospital, children

Introduction person to another, thus insuring continuity of care.4

Patient safety is an important healthcare quality Patients can experience transitions in their care up to
domain and its assurance represents a priority for 15 times during a five-day period of hospitalization,
health care systems. In clinical care settings, effective- and physicians may participate in as much as 3,000
ness of communication is essential and should be con-
sidered as an interactive process.1 Communication 1
Pediatric Intensive Care Unit, Hospital General de Ni~
nos “Pedro de
problems have long been noted as a major contributing
Elizalde”, Buenos Aires, Argentina
factor to sentinel events.2,3 2
Education and Research, Hospital General de Ni~nos “Pedro de Elizalde”,
Perhaps the most relevant moment for inter- Buenos Aires, Argentina
professional communication in daily clinical practice
Corresponding author:
interactions is the handoff of patient care between pro- Facundo Jorro Bar
on, Montes de Oca 40, City of Buenos Aires, CP:
viders. Handoffs refers to the process of transferring C1270AAN, Argentina.
role and responsibility for providing care from one Email: [email protected]
2 Journal of Patient Safety and Risk Management 0(0)

individual patient’s handoffs per month.5 Residents Population

and fellows involved in patient care have reported
First to third year pediatric internal medicine residents
that one of the main potential causes of adverse
during their terms of provision of care to patients in the
events (AEs) are issues related to handoffs.6
selected wards.
Furthermore, several studies have shown that an
effective and standardized communication between
caregivers at the moment of handoff is fundamental
Intervention
for patient safety since it anticipates and limits possible The I-PASS bundle consists in: an oral mnemonic, an
errors.4,7–12 The Joint Commission has recently estab- introductory workshop, a teamwork training based in
lished standardized transmission of information as a TeamSTEPPS, a printed handoff document, simulation
patient safety goal. Consequently, it advocates organ- exercises, faculty development, structured observation
izations to implement “a standardized approach to and feedback, and an I-PASS campaign.
handoff communications, including an opportunity to The I-PASS oral mnemonic stands for: I) Illness
ask and respond to questions”.13 severity, P) Patient summary, A) Action list,
The implementation of a teamwork training S) Situation awareness and contingency plans,
(TeamSTEPPS) together with a structured handoff S) Synthesis by the receiver.
tool known as I-PASS, has previously shown to TeamSTEPPS is a systematic approach, developed
decrease the number of medical errors and AEs.14–17 by the Department of Defense (DoD) and the Agency
I-PASS was developed in tertiary academic medical for Healthcare Research and Quality (AHRQ), that
centers in the United States and has only been studied aims to integrate teamwork to practice. It is designed
so far in that setting. Therefore, its effectiveness in to improve the quality, safety, and the efficiency of
locations that speak different languages, have different health care, based in four didactic-based modules: 1)
availability of resources (e.g. lack of electronic Leadership, 2) Situation monitoring, 3) Mutual sup-
medical records), belong to low and middle-income port, 4) Communication.18 The introductory workshop
countries, and are immersed in a different safety cul- included teamwork training based on leadership and
ture, remains unclear. communication modules, which includes 5 key ele-
Therefore, our study is intended to evaluate the ments: shared mental model, brief, debrief, check-
impact of an intervention to improve communication back, and cross monitoring. More than 80% of the
by implementing handoff standardization among pedi- residents of each ward attended an introductory work-
atric residents. Since an adequate communication shop for one and a half hour, while the remaining res-
between medical professionals is one of the pillars to idents received a computer based training with the
consider for improving healthcare quality. introductory workshop contents.
Our objective is to assess whether the implementa- Structured observations were done without feedback
tion of the I-PASS Handoff bundle in an argentine in the pre-intervention period. After the intervention,
pediatric hospital is associated with a reduction in the feedback was included at the end of the handoff based
rate of AEs and to evaluate its impact on time con- on improvement of capabilities.
sumption during handoffs and incidence of medical Finally, the I-PASS campaign included memory
prescriptions errors (MPE). aids, such as A3 posters with the mnemonics, printed
glasses with the logo and screen-savers in the wards’
workstations.
Methods The spanish I-PASS version was developed by the
investigators with the collaboration of investigators of
Study design the I-PASS Institute. A pilot implementation in anoth-
We conducted an exploratory, uncontrolled, pre-post er institution with collaboration of a principal investi-
study; between July 2017 and January 2018, in two gator of the I-PASS Institute took place before the
wards of Pedro de Elizalde Children’s General development of the study.
Hospital (HGNPE) in Buenos Aires, Argentina.
Wards were composed of 44 clinical and surgical pedi- Outcomes
atric hospital beds. At baseline, none of the two wards
had a standardized handoff program • Assessment of written and oral handoffs
The investigators obtained written consent from We determined the days of patient handoffs observa-
the subjects who participated and contributed to the tions through simple random sampling. We carried out
study data. at least 3 observations per week in each unit.
Jorro Bar
on et al. 3

The researchers completed a form to evaluate the analysis considering adherence to quality elements
adherence to key handoff elements (Supplement 1) described as: almost always, always; and
every day of the week excluding weekends; Sheets non-adherence: sometimes, almost never, never. We
were completed previous and after the intervention compared the pre versus post intervention dichoto-
for assessing changes with the application of I-PASS mous covariate using the Fisher’s exact test. To com-
bundle. pare time–motion data pre and post-intervention we
used the t-Student test. We compared AEs before and
• Medical errors and adverse events after the intervention by Wilcoxon rank sum test for
proportions. We considered p values less than 0.05 to
Different tools were used for the measurement of indicate statistical significance.
medical errors and AEs: All analyses were completed with STATA/IC for
Mac (2013 StataCorp LPVR ).
• GAPPS (global assessment of pediatric patient
safety): the methodology of the “trigger tool” has Ethics
been used for the detection of AEs through retro-
In accordance with the provisions from regulations
spective analysis.19,20 GAPPS proved to be reliable
applicable to medical research in institutions over-
in identifying and measuring triggers in medical
sighted by the Government of the City of Buenos
records (MR) leading to AEs.21 Discharged patients’ Aires, approval by the Research Ethics Committee
MR were randomly selected and reviewed. from the General Children Pedro Elizalde Hospital
• Inclusion criteria: hospitalized patients’ MR
was obtained (IF-2017–16583833-HGNPE).
between 07/01/2017 to 09/30/2017 (pre-interven- The participants signed an informed consent where
tion), and between 11/01/2017 to 01/31/2018 (post- they freely decided to participate in the study.
intervention).
• Exclusion criteria: incomplete MR, hospitalization
shorter than 24 hours, MR of patients hospitalized Results
for psychiatric reasons or social reasons. We measured pre-intervention outcomes of interest
• Error reporting Mailbox: a mailbox was placed in during a three-month period on 14 pediatric residents,
each ward for reporting AEs detected in anony- from July to September 2017. The intervention was
mously way. implemented during October 2017 (one month). After
• Medical prescription errors (MPE) data collection that, data was collected from November 2017 to
worksheet: all inpatient medical’s prescriptions January 2018 (three months). All selected residents
were reviewed on tuesday, wednesday and thursday used the I-PASS handoff bundle during the interven-
during the first and third week of each month along tion. Based on direct and standardized observations,
the study. The incidence, type of MPE, and severity handoff feedback was provided to residents in the post-
according to the classification of the Ruiz-Jarabo intervention period.
group were determined.22
• Survey to evaluate physician’s satisfaction & percep- Handoff quality
tion: the residents of each ward answered a survey
the last month of each period between 4 to 8 hours We evaluated the adherence to key handoff elements
after receiving a patient’s handoff.10 based on the observation tool. A total of 115 observa-
tions were reviewed (56 observations in the pre-
intervention period and 59 in the post-intervention
Sample size and statistical analysis
period). We observed an overall key handoff elements
The sample size was calculated as AEs per 100 admis- compliance of 25% pre-intervention versus 61% post-
sions. We used as a reference the AEs measured in the intervention (p < 0.0001). The global adherence to the
study carried out in 2016 at HGNPE, that showed an ten handoff items evaluated was 56.6% pre-
incidence of 30 AEs per 100 admissions.20 intervention versus 76% post-intervention (p ¼ 0.023).
We estimated a 20% decrease in AEs, based on pre- In the pre-intervention period, the most used key ele-
vious studies.15 We calculated 132 MR to be reviewed ment was the patient’s summary (66%), while the key
per period;23 to obtain a power of 80%, with an alpha element least utilized was the illness severity (9%). In
error <0.05. The variables were expressed as a percent- the post-intervention period, the key element that
age according to their distribution, mean and standard increased its application the most was the action list
deviation or median and interquartile range. (18% pre-intervention versus 80% post-intervention)
The results collected from the observation forms followed by illness severity (9% pre-intervention
were grouped into a dichotomous scale for statistical versus 57.5% post-intervention) (Table 1).
4 Journal of Patient Safety and Risk Management 0(0)

Table 1. Compliance with quality elements of handoff.

Preintervention Postintervention p

Observations (number) 56 59
llness Severity 9% 57.5% 0.0000
Summary of the patient 66% 77% 0.191
Action List 18% 80% 0.0000
Situation Awareness & Contingency Planning 12.5% 34.5% 0.005
Synthesis By Receiver 21.5% 54% 0.0003
All 5 key elements 25% 61% 0.0001
Global (10 items*) 56% 76% 0.023
*Global: Handoff duration, Accuracy of Illness Severity Assessments, Quality of Patient Summaries, Omissions of important information,
Irrelevant information, plus 5 key elements.

Figure 1. Preventable adverse events detected by GAPPS.

Table 2. Preventable and non-preventable adverse events with the use of GAPPS tool.

Preintervention Postintervention p

Adverse events (n) 17 6 0.015

Preventable adverse events (N) 16 6 0.025
Type of AEs (n): 3 1 0.285
 Related to the diagnosis 6 1 0.052
 Related to the treatment 1 1 1.000
 Falls 6 3 0.324
 Healthcare-associated infection

No difference was observed in the time used period (6 preventable AEs and 0 non-preventable
for the handoff in both periods (pre-intervention AEs), indicating 12.9 and 4.5 AEs per 100 admissions
5.5  0.2 and post-intervention 5.3  0.3 minutes per respectively (IC95: 0.010; 0.142; [p ¼ 0.025]). This result
patient [p ¼ 0.59]). represents a 65% decrease of AEs post-intervention
(Figure 1). Considering only preventable AEs in both
Medical errors and adverse events periods, we verified an incidence of 12.1 in the pre-
We reviewed a total of 264 medical records (132 in each intervention period and 4.5 in the post-intervention
period) using GAPPS. We observed 17 possible AEs in period per 100 admissions (IC95: 0.0101; 0.142; [p ¼
the pre-intervention period (16 preventable AEs and 1 0.025]), representing a decrease of 62.8%. Types of
non-preventable AEs) and 6 in the post-intervention detected AEs are shown in Table 2.
Jorro Bar
on et al. 5

We reviewed a total of 5715 prescriptions (pre-interven- of the items related to patient care were improved in
tion period, 3590; post-intervention, 2125 prescriptions). the post-intervention period. We did not observe
There was no significant change in the rate of MPE (11.5 changes in communication of the patient, family care
pre-intervention versus 9.9 post-intervention errors per plan and patient family dissatisfaction. Residents
100 prescriptions [p ¼ 0.06]). We found more severe reported a higher percentage of handoff AEs, more
MPE in the pre-intervention period, class B (pre-interven- negative events, and more handoff interruptions in
tion 49, post-intervention 83 errors per 100 prescriptions the preintervention period. They also reported a
[p ¼ 0.0001]) and class C (pre-intervention 0.9, post- higher common understanding of the patient status at
intervention 1.9 errors per 100 prescriptions [p ¼ 0.003]). the end of the study (Table 3).
We observed a higher number of class A MPE (less
severe) in the post-intervention period (50 post- Discussion
intervention class A errors vs 15 pre-intervention errors
per 100 prescriptions [p ¼ 0.0001]). Medical errors and adverse events
We collected a total of 12 AEs pre-intervention and 4
We found that implementation of a spanish version of
AEs post-intervention in the assigned error mailboxes.
the I-PASS Handoff Bundle in two argentine pediatric
inpatient units, was associated with a 65% relative
End of shift surveys reduction in the rate of preventable AEs. We also
We took a convenience sample of 39 end of shift sur- found non statistically significant decrease in MPE
veys (20 pre-intervention, 19 post-intervention). Most rate, with a favorable change in the severity according

Table 3. Results of the end of shift survey according to the intervention period.

Did you observe any of the following events during your Preintervention Postintervention
patient’s care today in the morning? (N ¼ 20) % (N ¼ 19) %

Lack of availability of adequate equipment for patient care 35 24.1

A translator is missing (patient not Spanish speaker) 5.2 5.2
Unresolved custody issues (patient prosecuted) 5.2 31.6
Intravenous fluids administered in the wrong way (flow, composition or incorrect volume) 40 15.8
Uncertain plan for drainage and catheters 30 10.5
Wrong diet 35 26.3
The professional in charge of the patient during the previous guard was not identified 11.1 5.2
Missing interconsultation request 45 26.3
Fasting not respected 20 5.2
Studies or medication not corresponding to the patient 25 5.2
Problems with breastfeeding/formula 70 5.2
Consent problems 15 0
Incorrect procedures/studies/medications 30 15.8
Delay in procedures/studies/medications 65 24.1
Duplicate or untimely studies/medications 65 31.6
Incomplete or incorrect preventive measures for 60 24.1
infections (isolation, hand washing, etc)
Delay in discharge 65 31.6
Lack of communication of the patient/family care plan 25 26.3
Patient/family dissatisfaction 25 21
Serious adverse event 0 15.8
Unmanaged medication 40 26.3
Diagnostic test or incorrect laboratory result 5.2 10.5
Do you consider that the adverse events observed 30 21
were related to the handoff/non-handoff?
Have you detected other types of negative events related to the transfer? 11.1 0
Do you consider that the interruptions and/or 20 10.5
distractions during the transfer were minimal or non-existent?
I know my patients’ problems and their clinical condition 100 94.8
I understood what are the actions that my patients require 100 94.8
I know when I should worry about my patients 100 100
I know when and how to increase my concern for my patients 100 94.8
Is there a common understanding of patients? 60 89.5
6 Journal of Patient Safety and Risk Management 0(0)

to the proposed classification. This AEs reduction we think applies to our study.28 According to their
occurred without an increase in the time required to study describing resident experiences with implementa-
complete handoffs. tion of the I-PASS bundle, other important active com-
In concordance with our results, the initial study I- ponents were identified in this complex intervention
PASS implementation by Starmer et al., as a single such as auto-importing of patient data into the elec-
center experience, showed a decrease in AEs from tronic handoff document, improvements in the handoff
33.8 per 100 admissions (95% CI, 27.3–40.3) to 18.3 environment, and improvements in the teamwork and
per 100 admissions (95% CI: 14.7–21.9, P < 0.001).14 communication skills. Moreover, they observed that
Furthermore, in a study done in 9 pediatric residency strict adherence to the I-PASS bundle may not neces-
programs belonging to hospitals in the United States sarily lead to the achievement of the desired outcomes.
and Canada it was observed a relative reduction of In our study, the synthesis and feedback component
23% in medical errors and a 30% reduction in prevent- were the most challenging features of handoffs. The
able adverse events after I-PASS implementation.15 A mentioned features were also shown to be the most
decrease in diagnostic, clinical history and physical
challenging in previous reports.15,29
examination related AEs was reported. However, Lastly, duration of handoff was not significantly
there was no change in errors related to medication,
increased using I-PASS. Thus, the hand-off time
procedures or nosocomial infections. Both publications
remained almost constant while achieving overall
reported that there were no changes in physicians’
higher rates of inclusion of essential patient informa-
workload or time spent in handoffs when using I-
tion confirming observations from previous studies.30
PASS bundle. Sheth et al. demonstrated that an I-
PASS–supported handoff process was associated with
improved transfer efficiency and safety culture when End of shift survey
executing I-PASS in handoffs between the cardiovas- In surveys answered by handoff receiver physicians, we
cular intensive care unit to an acute care unit.24 Bigham verified improvements in most points related to the
et al. also showed a significant decrease in errors relat- perception of AEs. Nevertheless, these results could
ed to handoff after the use of a standardized tool in 23 not be compared due to the small sample size. No var-
pediatric hospitals.10 iation was identified in percentages related to commu-
After our intervention, we observed a decrease in the nication with the patient’s family. This was not an
AEs reported via the error mailbox system which was expected outcome since this topic was not addressed
very similar to the decrease detected with the use of by our intervention. Surprisingly, we observed high
GAPPS. In contrast, the AEs identified via different baseline levels of receiver understanding of patients
methods that we employed were not the same. care problems after handoffs. We speculate that this
Nevertheless, the decrease in self-reported AEs high baseline level resulted from a lack of awareness
cannot be exclusively attributed to the intervention
of the ineffectiveness of the handoff process.
implemented.
Fortunately, common understanding of patients was
Although AEs occurred frequently, our rates include
maintained throughout the study. Other studies have
very small and some serious errors and are consistent,
shown similar results regarding the handoff process
or even lower, with the rates found in numerous other
satisfaction and handoff intervention.10
studies using the same intensive surveillance meth-
ods.20,25,26 At the beginning of the implementation of
the I-PASS bundle, the average adherence to items in Limitations
the procedure was similar to the adherence observed in Among the limitations of our study we can mention its
different centers. After our quality improvement imple- design and representativeness since this is an explorato-
mentation, a significant difference was observed.14,15,27 ry study that took place in two hospital wards of a
single institution. That precludes us from establishing
Handoff quality a definite causal link between the I-PASS Handoff
In the post-intervention period, we observed an adher- Bundle implementation and any improvement in
ence of approximately 60% to the five key handoffs patient safety. In addition, the external validity of the
elements which was similar to the adherence detected survey regarding error perception was not evaluated in
in the previous studies and significantly better than the this study. Furthermore, physician’s behavior and their
pre-intervention period.15 In addition, as observed by use of I-PASS format may have been influenced by the
Coffey et al., an improvement in patient safety can be observer’s presence. Additionally, the severity of
observed regardless of inconsistent adherence to the patients’ affections in both periods could not be
mnemonic during verbal handoff, explanation which assessed to ensure their similarity. Finally, patients
Jorro Bar
on et al. 7

involved were hospitalized in different seasons of the Ethical approval

year which might have caused seasonal bias. In accordance with the provisions from regulations applicable
The application of the I-PASS bundle in our cohort to medical research in institutions oversighted by the
of medical providers which combined and applied Government of the City of Buenos Aires, approval by the
together several domains (teamwork training, mne- Research Ethics Committee from the General Children
monics, observations and feedback) prevented us Pedro Elizalde Hospital was obtained (IF-2017-16583833-
HGNPE).
from determining which element of the intervention
was the most effective. Still, we adopted this approach
Funding
given that transitions of care are known to endanger
the quality of patient care and patient safety and it has The author(s) received no financial support for the research,
been demonstrated to be a successful strategy in a authorship, and/or publication of this article.
number of previous studies.31–33
ORCID iDs
Facundo Jorro Baron https://orcid.org/0000-0001-6887-
Conclusion 9275
We conclude then that the implementation of an span- Lucila Valentini https://orcid.org/0000-0001-5995-4931
ish version I-PASS bundle in two pediatric wards of an
argentine tertiary care center was associated with a sig- Supplemental Material
nificant reduction in the rate of AEs, improvements in Supplemental material for this article is available online.
handoff quality without modifying duration and it was
not associated with a significant reduction in MPE. References
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