The handoff is not over when the doctor going home stops talking. It is over when the doctor staying has said it all back.
That is the last letter of I-PASS, a routine for the moment one young doctor hands their patients to another at the end of a shift. Illness severity first. Then a patient summary, an action list, and situational awareness and contingency planning. Then the S that closes it: synthesis by receiver, the incoming doctor summarizing what they just heard to the person who said it.
Christopher Landrigan and Amy Starmer, pediatricians at Boston Children’s Hospital, built it because of a gap they had noticed. Residents were drilled to take histories with templates and to present cases in a set format on rounds. At shift change, when a patient passed to someone new, that structure was largely absent, and the person leaving could be tired and rushed. Rules limiting residents’ working hours had made the moment more common: shorter shifts meant more handoffs.
They tried an early version on two units at Boston Children’s in 2009 and 2010: training, a spoken mnemonic, a new team structure for handoffs. Medical errors fell from 33.8 to 18.3 per 100 admissions. Handoffs also moved somewhere calmer. Before, about a third happened in a quiet spot. After, about two thirds did. But it was one hospital and 1,255 admissions.
So the team took it to pediatric residency programs at nine hospitals in the US and Canada, from Toronto’s Hospital for Sick Children to Walter Reed. At each site, six months of watching handoffs as they were, six months of training, six more of watching. Researchers actively searched for errors, recorded spoken handoffs and checked the printed handoff sheets.
The obvious price was time: a fixed script and a read-back for every patient, at the end of a long shift. Starmer later recalled that there had been “much more resistance” to the idea back then. Time-motion observers settled it. Spoken handoffs took 2.4 minutes per patient before and 2.5 after, not a significant difference.
Across 10,740 admissions, published in the New England Journal of Medicine in November 2014, medical errors fell 23%, from 24.5 to 18.8 per 100 admissions. Preventable adverse events, errors that actually hurt a child, fell 30%, from 4.7 to 3.3. Six of the nine sites saw a significant drop on their own.
One number stayed put. Nonpreventable adverse events, harm that better communication could not have stopped, went from 3.0 to 2.8, not a significant change. Had both kinds fallen, explained Lauren Destino, a co-author at Stanford, the hospitals might simply have been seeing healthier or lower-risk patients. “That suggests that it was the improved handoffs themselves that led to the reduction in errors,” she said. It was still a before-and-after study, and the paper said the program was “associated with” fewer errors.
By 2022, Starmer and Landrigan had co-founded a company, the I-PASS Patient Safety Institute, to help hospitals adopt the program. Boston Children’s own article that year disclosed that both hold equity in it, as does the hospital. The same article reported a follow-up in 32 hospitals, adult and community hospitals among them. Before I-PASS, incoming doctors gave a high-quality synthesis of what they had been told 31% of the time. Afterward, 83%.