I-PASS Adherence and Implications for Future Handoff Training
Open accessAbstract
Background: A formal handoff process, such as the I-PASS handoff program, can improve communication about patients among residents. Faculty observation of resident handoffs has served as the primary method for documenting adherence to I-PASS, and little is known about residents' use when they are not being observed. Objective: We determined how frequently pediatric residents use I-PASS when not being observed. Methods: We implemented I-PASS in the 2016–2017 academic year and anonymously surveyed residents (December 2016 and June 2017), asking them how they perceive the effectiveness of I-PASS at enhancing patient safety, their frequency of I-PASS use when not observed, co-residents' frequency of use, and open-ended questions regarding factors affecting use. Results: Fifty-one (52%) and 50 (51%) of 99 eligible residents completed the December and June surveys, respectively. All respondents thought I-PASS had some effectiveness in enhancing patient safety. In December, only 6 (12%) residents stated they used I-PASS more than 75% of the time and reported providing a synthesis statement during handoffs more than 75% of the time. The results were similar for both surveys. Commonly cited reasons for not using I-PASS included time (n = 30), prior knowledge of patients (n = 20), and patients with limited complexity (n = 9). Conclusions: While most residents thought I-PASS was effective at enhancing patient safety, many reported that they do not use all 5 elements in most of their handoffs when not being observed. Barriers reported included time, familiarity with patients, and limited patient complexity.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
The data surrounding surgical patients are voluminous and diverse while simultaneously incomplete, which strains the ability of receiving nurses to review and assimilate it de novo.
“The data surrounding surgical patients are voluminous and diverse while simultaneously incomplete, which strains the ability of receiving nurses to review and assimilate it de novo.8–10”
From Potential uses of AI for perioperative nursing handoffs: a qualitative study (2023) · cites this paper as [8]
The Background and Conclusion (pages unavailable) address I-PASS use during pediatric resident handoffs, not receiving nurses reviewing surgical-patient data. The Results mention complex patients and time constraints, but do not address the claimed volume, diversity, or incompleteness of surgical-patient data. Searches for surgical patients, receiving nurses, and incomplete handoff information found no supporting passage. (LLM, conf=0.76)
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009) · Journal of Biomedical Informatics · doi:10.1016/j.jbi.2008.08.010 · Cited by 51,384 · see citing works
Starmer, A. J., Sectish, T. C., Simon, D. W., Keohane, C., McSweeney, M. E., Chung, E. Y., Yoon, C. S., Lipsitz, S. R., Wassner, A. J., Harper, M. B., et al. (2013) · JAMA · doi:10.1001/jama.2013.281961 · Cited by 337 · see citing works
I-PASS, a Mnemonic to Standardize Verbal Handoffs
Starmer, A. J., Spector, N. D., Srivastava, R., Allen, A. D., Landrigan, C. P., Sectish, T. C., & the I-PASS Study Group (2012) · Pediatrics · doi:10.1542/peds.2011-2966 · Cited by 300 · see citing works
Self-citationStarmer, A. J., O’Toole, J. K., Rosenbluth, G., Calaman, S., Balmer, D., West, D. C., Bale, J. F., Yu, C. E., Noble, E. L., Tse, L. L., et al. (2014) · Academic Medicine · doi:10.1097/acm.0000000000000264 · Cited by 186 · see citing works
Self-citationChanges in Medical Errors with a Handoff Program
Starmer, A. J., & Landrigan, C. P. (2015) · New England Journal of Medicine · doi:10.1056/nejmc1414788 · Cited by 48 · see citing works
Starmer, A. J., Spector, N. D., West, D. C., Srivastava, R., Sectish, T. C., Landrigan, C. P., Landrigan, C. P., Spector, N. D., Starmer, A. J., Sectish, T. C., et al. (2017) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/j.jcjq.2017.04.001 · Cited by 39 · see citing works
Self-citationI-PASS Handoff Curriculum: Faculty Observation Tools
Starmer, A. J., Landrigan, C. P., Srivastava, R., Wilson, K. M., Allen, A. D., Mahant, S., Noble, E. L., Sectish, T. C., Blank, J. S., Tse, L. L., et al. (2013) · MedEdPORTAL · doi:10.15766/mep_2374-8265.9570 · Cited by 29 · see citing works
Self-citationResident Experiences With Implementation of the I-PASS Handoff Bundle
Coffey, M., Thomson, K., Li, S., Bismilla, Z., Starmer, A. J., O’Toole, J. K., Blankenburg, R. L., Rosenbluth, G., Cole, F. S., Yu, C. E., et al. (2017) · Journal of Graduate Medical Education · doi:10.4300/jgme-d-16-00616.1 · Cited by 24 · see citing works
Self-citationI-PASS Handoff Curriculum: Core Resident Workshop
Spector, N. D., Starmer, A. J., Allen, A. D., Bale, J. F., Bismilla, Z., Calaman, S., Coffey, M., Cole, F. S., Destino, L., Everhart, J. L., et al. (2013) · MedEdPORTAL · doi:10.15766/mep_2374-8265.9311 · Cited by 17 · see citing works
Self-citationO’Toole, J. K., West, D. C., Starmer, A. J., Yu, C. E., Calaman, S., Rosenbluth, G., Hepps, J. H., Lopreiato, J. O., Landrigan, C. P., Sectish, T. C., et al. (2014) · Academic Pediatrics · doi:10.1016/j.acap.2014.02.013 · Cited by 15 · see citing works
Self-citationI-PASS Mentored Implementation Handoff Curriculum: Champion Training Materials
O’Toole, J. K., Starmer, A. J., Calaman, S., Campos, M., Hepps, J. H., Lopreiato, J. O., Patel, S. J., Rosenbluth, G., Schnipper, J. L., Sectish, T. C., et al. (2019) · MedEdPORTAL · doi:10.15766/mep_2374-8265.10794 · Cited by 10 · see citing works
Self-citation
Flagged first, then by citations
Research works printed but not linked: 1
- [12]Ritchie J, Lewis J. Qualitative Research Practice: A Guide for Social Science Students and Researchers. Thousand Oaks, CA: SAGE Publications Ltd;; 2003. [Google Scholar]
Cited by
Sorted by citations
Potential uses of AI for perioperative nursing handoffs: a qualitative study
King, C. R., Shambe, A., & Abraham, J. (2023) · JAMIA Open · doi:10.1093/jamiaopen/ooad015 · Cited by 27 · see citing works
Effect of a Multispecialty Faculty Handoff Initiative on Safety Culture and Handoff Quality
Fitzgerald, K. M., Banerjee, T. R., Starmer, A. J., Caplan, G., Al-Kuwari, M., Hillier, D. F., & Stack, A. M. (2022) · Pediatric Quality and Safety · doi:10.1097/pq9.0000000000000539 · Cited by 11 · see citing works
Comparison of a Nurse-Nurse Handoff Mnemonic With Real-World Handoffs
O’Rourke, J., Lopez, K. D., Riesenberg, L. A., & Abraham, J. (2020) · Journal of Nursing Care Quality · doi:10.1097/ncq.0000000000000465 · Cited by 9 · see citing works
Addition of CORES to the I-PASS Handoff: A Resident-led Quality Improvement Study
Tufts, L. M., Damron, C. L., & Flesher, S. (2020) · Pediatric Quality and Safety · doi:10.1097/pq9.0000000000000251 · Cited by 9 · see citing works
Anesthesiology Patient Handoff Education Interventions: A Systematic Review
Riesenberg, L. A., Davis, R., Heng, A., do Rosario, C. V., O’Hagan, E. C., & Lane-Fall, M. B. (2022) · The Joint Commission Journal on Quality and Patient Safety · doi:10.1016/j.jcjq.2022.12.002 · Cited by 8 · see citing works
Michael, M. M., Griggs, A. C., Shields, I. H., Sadighi, M., Hernandez, J., Chan, C., McHugh, M., Nichols, B. E., Joshi, K., Testa, D., et al. (2021) · BMC Medical Education · doi:10.1186/s12909-021-02943-x · Cited by 5 · see citing works
Handoffs, Care Transitions, and Readmissions
Bordin-Wosk, T., Klubnick, J., O’Toole, J. K., Jenkins, I., & Donato, J. (2025) · Medical Clinics of North America · doi:10.1016/j.mcna.2025.02.016 · Cited by 4 · see citing works
Self-citationOmidi, A., Rajabalipour, M., arab, S., & Sorkhan, T. M. (2023) · Payām-i naw. · doi:10.61186/jgbfnm.20.2.1 · Cited by 2 · see citing works
Abdelrahman, M. M., Hashem, R., El-boudy, D. F., & Elsehrawy, M. G. (2026) · Journal of Clinical Nursing · doi:10.1111/jocn.70310 · Cited by 1 · see citing works
Zvonar, I., Griffith, M., Garrett, A., Watsjold, B. K., Welsh, L. A., Beaulieu, A. M., Ilgen, J. S., & Jauregui, J. (2026) · Academic Medicine · doi:10.1093/acamed/wvag252 · Cited by 1 · see citing works
Improving Patient Handoffs and Transitions in Care Among Residents: A Chief Resident-Led Initiative
Marquez, M., Gonzalez, A., Moufarrej, Y., & Vijayan, V. (2024) · Cureus · doi:10.7759/cureus.73282 · Cited by 1 · see citing works
Analisis Metode Vertikal Handoff Pada Jaringan UMTS
Pradika, A. (2022) · Jurnal Minfo Polgan · doi:10.33395/jmp.v10i2.11455
Evaluation of a Standard Handover Tool at a Pediatric Tertiary Care Unit in Oman
Riyami, H. A., Al-Makhmari, S., Balushi, S. A., Abri, S. A., & Jabri, M. A. (2023) · Cureus · doi:10.7759/cureus.43088
“Left Seat, Right Seat”: Transitions of Care Within Graduate Medical Education
Denson, J. L., & Bateman, K. M. (2025) · Journal of Graduate Medical Education · doi:10.4300/jgme-d-25-00174.1 · Cited by 1 · see citing works
Ensuring Continuity of Emergency Care During Patient Handover
de Lange, S., Mamalelala, T. T., & Botes, M. (2026) · Nursing Clinics of North America · doi:10.1016/j.cnur.2025.12.001
Nursing shift handover methods and their impact on patient safety
Kavitha, N. K., Rami, M. A., Vanaja, P., K., M. A., M, J. J., Israel Jeba Prab, D., Lakshimi, K., Katiyar, J., Umar, M., & Prabha, N. (2026) · International Journal of Research in Medical Sciences · doi:10.18203/2320-6012.ijrms20260976
Maza, E. M. T., Palau, V. N., Lema-Vélez, M., Gnecco-González, S., Landinez, A. C., & Alarcón, A. C. C. (2026) · BMC Medical Education · doi:10.1186/s12909-026-09299-0
Ahmed, R. I. O., Mohamed, I. M., Abdelmoneim, O. K., & Mohammedelamin, M. A. (2026) · Cureus · doi:10.7759/cureus.109814
Zaidi, M., Tanguay, A., Zaidi, N., Sial, Q., GAZARIAN, P. K., Thakral, M., Walfre, F., & Dykes, P. C. (2026) · doi:10.2196/preprints.102954
Structured Interfacility Handoffs: How Do We Define Success?
Woodruff, A. G., & McCrory, M. C. (2026) · Pediatric Critical Care Medicine · doi:10.1097/pcc.0000000000003999
- Authors
- Hughes, H. K., Serwint, J. R., O'Toole, J. K., Spector, N. D., & Ngo, T. L.
- Affiliations
- Johns Hopkins University (US)
- Helen K. Hughes, MD, MPH, is Assistant Professor of Pediatrics and Associate Program Director, Harriet Lane Pediatric Residency Program, Johns Hopkins University School of Medicine; Janet R. Serwint, MD, is Professor Emeritus and Former Pediatric Residency Program Director, Harriet Lane Pediatric Residency Program, Johns Hopkins University School of Medicine; Jennifer K. O'Toole, MD, MEd, is Asso
- Corresponding author
- Hughes, Helen K.
- Venue
- Journal of Graduate Medical Education
- Published
- 2019-06-01
- Volume
- 11
- Issue
- 3
- Pages
- 301-306
- ISSN
- 1949-8349 (ISSN-L)
- 1949-8357
- PMC
- PMC6570451
- OpenAlex
- W2944384152
- Cited by
- 21
- References
- 11
- Citations by year
- 2026: 8 · 2025: 2 · 2024: 1 · 2023: 3 · 2022: 3 · 2021: 2 · 2020: 2
- FWCI
- 2.03
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Graduate Medical Education (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
- Keywords
- patient handover, patient safety, pediatric residents
- MeSH terms
- Continuity of Patient Care, Hospitals, Pediatric, Humans, Internship and Residency, Maryland, Pediatrics, Surveys and Questionnaires, Patient Safety, Patient Handoff
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
