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Better handoffs. Safer care.
Plan for the Day
Format• 2 hour curricular introduction• 1 hour in breakout groups for
handoff simulation Worksheet Breaks Transitions Next steps Evaluation
2
Overview
Introduction• Role of communication in medical
errors Team Training: The
TeamSTEPPSTM Model The I-PASS Handoff• Content, structure, and process• Verbal• Printed
Handoff Simulation Exercise3
Overall Learning Objectives
Describe the importance of effective communication in reducing medical errors
Apply effective team training strategies to improve handoffs
Detail the essential content and sequence of effective handoffs
Practice handoff skills
4
Role of Communication in
Medical Errors
5
National Patient Safety Goal
Improve the effectiveness of communication among
caregivers 6
Photo courtesy of Comstock Images/Comstock/Thinkstock
Root Causes of Sentinel Events
Joint Commission. (2011). Sentinel Event Statistics Data - Root Causes by Event Type
(2004 - Third Quarter 2011)1
7
Communication Failures
Can happen even with well-intentioned individuals• Game of “Telephone”• Email address auto-complete
8Photo courtesy of Istvan Takacs/Wikimedia Commons
New ACGME Training Requirements
Teamwork training Communication skills during
transitions of care Supervision and monitoring of
handoffs
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Team Training: The TeamSTEPPSTM
Model
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TeamSTEPPSTM
Evidence-based team training curriculum
High performing teams• Must have effective leaders• Use structured communication
strategies• Develop situational awareness• Provide mutual support
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Team Strategies and Tools to Enhance Performance and Patient Safety
Multi-team System
12
Core TeamCore Team
Ancillary Services
Coordinating Team
Administration
Contingency Team
Support Services
Patient Care
Building a Shared Mental Model
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When Mental Models are Not Shared
Example: When your child takes the bus home and you thought the plan was to pick him up at school
14
Photo courtesy of H. Michael Miley/Wikimedia Commons
Structured Team Communication Techniques
Technique Function
Brief Plan team activities
Debrief Analyze an interim event
Huddle Solve a problem
Cross monitoring / Feedback
Improve performance
Assertive statement
Identify potential errors
Check-back Ensure accurate information transfer
Handoff Transfer care and responsibility
15
Structured Team Communication Techniques
Technique Function
Brief Plan team activities
Debrief Analyze an interim event
Huddle Problem solve
Cross monitoring / Feedback
Improve performance
Assertive statement
Identify potential errors
Check-back Ensure accurate information transfer
Handoff Transfer care and responsibility
16
Video Review and ReflectionBriefs, Debriefs, Huddles
Refer to the Observation Form for Structured Team Communication Techniques
For each video clip• Review the checklist• Record your reflections
Large group discussion afterwards
17
BriefEssential to Team
Planning
• Engages team members in short-term planning
• Provides a “pre-game” team meeting
18
Brief
19
20
DebriefEssential to
Improvement
Improves teamwork skills and patient outcomes
Reconstructs and analyzes interim events
21
Debrief
22
23
HuddleEssential to Solve
Problems
Is an opportunity to touch base and regain situation awareness
Focuses on critical issues and emerging events
24
Huddle
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26
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Large Group Discussion:Briefs, Debriefs, Huddles
Structured Team Communication Techniques
Technique Function
Brief Plan team activities
Debrief Analyze an interim event
Huddle Solve a problem
Cross monitoring / Feedback
Improve performance
Assertive statement
Identify potential errors
Check-back Ensure accurate information transfer
Handoff Transfer care and responsibility
28
Video Review and Reflection:Cross Monitoring and Feedback
Assertive Statement
Refer to the Observation Form for Structured Team Communication Techniques
For each video clip• Review the checklist• Record your reflections
Large group discussion afterwards
29
Cross MonitoringAn Essential Technique
Monitor actions of your team members
Provide a safety net for your team
Recognize and address errors actively
‘Watch each other’s back’
30
FeedbackEssential for Cross Monitoring
Focuses on team performance and improvement
Provides a learning opportunity
31
Cross Monitoring / Feedback
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Advocacy and AssertionStrategy for Avoiding Errors
When viewpoints differ• Advocate for the patient• Make assertive statement• Open the discussion• State the concern• Offer a solution• Obtain an agreement
34
Advocacy and Assertion
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Large Group Discussion:Cross Monitoring / Feedback
Assertive Statement
37
Structured Team Communication Techniques
Technique Function
Brief Plan team activities
Debrief Analyze an interim event
Huddle Solve a problem
Cross monitoring / Feedback
Improve performance
Assertive statement
Identify potential errors
Check-back Ensure accurate information transfer
Handoff Transfer care and responsibility
38
Check-Back
39
Check-Back in Our Daily Lives
Ordering take-out
Customer service at a call center
40
Photo courtesy of Dslninja/Wikimedia Commons
Handoffs Transfer of:• Information • Authority• Responsibility
Occur during transitions in care• Shift changes• End of service
block• Unit transfers• Discharges
41
Structured Team Communication TechniquesTechnique Function Example
Brief Plan team activities
Day one discussion for team orientation
Debrief Analyze an interim event
Recap of events at the end of a shift
Huddle Problem solve Planning for a procedure
Cross monitoring / Feedback
Improve performance
Commenting about a decision (selected test)
Assertive statement
Advocate for safe, high quality care
Recognizing a potential error
Check-back Ensure accurate information transfer
Reading back a verbal order
Handoff Transfer care and responsibility
Transitions of care
42
Essentials of Team Function
43
Key Points
TeamSTEPPSTM can be used to develop effective communication strategies
Effective communication is critical to ensure effective handoffs of care
Development of a shared mental model is critical to the handoff process
44
•Have you experienced a verbal handoff when team members left with vastly different impressions of the acuity of patients on the unit?
•Have you experienced consultants who formed different conclusions about an individual patient based on their own biases or a narrow perspective?
Shared Mental Model Exercise
45
The I-PASS Handoff
46
Global Elements of Handoffs
Unambiguous transfer of • Information• Responsibility
Protected time and space• Quiet location• Interruptions minimized
Standardized format Importance of the leader• Assign roles, ensure quality
47
Learning Styles
Active Reflective
Sensing Intuitive
Visual Verbal
Sequential Global
48http://www.engr.ncsu.edu/learningstyles/ilsweb.html
Learning Styles Exercise
Pair share with a partner Review your learning styles • Based on inventory completed
before workshop
Interview each other Elicit 2 techniques• To enhance the way you receive
information
Large group debrief
49
Elements of Verbal Handoffs
Structured format • Begins with high-level overview
Appropriate pace Closed-loop communication
shared mental model• Solicit check back of salient points• Prompt for clarifying questions• Be aware of non-verbal
communication• Nodding approval, eye rolling, puzzled look
50
The Printed Handoff Document
Supplements the verbal handoff• Allows receiver to follow• Provides more comprehensive
information Creates efficient information transfer Requires daily updates• High-quality information
• Don’t copy and paste
• Senior/supervising resident should edit and ensure quality
51
Verbal Handoff ComplementsPrinted Handoff Tool
Printed handoff is foundation Content / length of verbal handoff depends
on• Level of training• Prior contact with and knowledge of
patients• Length of time on rotation
• Verbal summary is more lengthy during handoffs on the first few days of the rotation
Should provide an opportunity for discussion• Creates a shared mental model• Facilitates active participation by receiver
52
53
Large Group Discussion
What techniques did they use that were particularly effective?
What pitfalls did you notice?
54
Mnemonic Provides Organizational Framework
Standard language Sequence Key elements Memory aids• Catchy• Symbolic• Utilitarian• Parsimonious• May conjure up a visual image
55
The I-PASS Mnemonic
I Illness SeverityStable, “Watcher,” Unstable
P Patient SummarySummary statement; events leading up to admission; hospital course; ongoing assessment; plan
A Action ListTo do list; timeline and ownership
S Situation Awareness & Contingency PlanningKnow what’s going on; plan for what might happen
S Synthesis by ReceiverReceiver summarizes what was heard; asks questions; restates key action/to do items
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Key Points Effective handoffs
• Ensure transfer of accurate information
• Facilitate transfer of responsibility
Verbal handoffs• Are structured• Employ closed-loop
communication Printed handoff documents
• Provide more detail• Integrate with verbal
handoffs
57
Photo courtesy of Comstock/Comstock/Thinkstock
58
Illness SeverityWhy is it important to classify?
Focus attention appropriately Use standard language May vary based on• Unit acuity• Provider type• Institutional culture
Helps develop shared mental model
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Illness SeverityA Continuum
Watcher : any clinician’s “gut feeling” that a patient is at risk of deterioration or “close to the edge”
60
Illness SeverityAssessment
Be aware of using these terms• Printed document may be
considered part of medical record• Potential for incorrect assignment• Changes in patient status
Make assessment during verbal handoff
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The Patient SummaryWhy is it Important?
Describes succinctly• Reason for admission• Events leading up to admission• Hospital course by
problem/diagnoses• Plan for hospitalization
Communicates concerns and nuances
Anticipates expected course Creates a shared mental model
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Sections of a Patient Summary
Summary statement Events leading up to
admission Hospital course Ongoing assessment• Organized by
problems/diagnoses Plan • Organized by
problems/diagnoses
64
Summary Statement Section
“One-liner” Sets the clinical
context Contains critical
identifying information• Name• Age• Gender• Pertinent past
history• Reason for
admission65
Events Leading Up To Admission Section
Lists chronologically
Includes essential history & physical exam/lab findings
Should be bulleted Section can be
truncated when high level of diagnostic certainty is attained
66
Hospital Course Section
Lists key events and updates
Highlights special considerations • Family/social issues• Nursing concerns• Chronic medical
conditions
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Ongoing Assessment Section
Provides diagnostic reasoning
Offers differential diagnosis and assessment
Uses appropriate organizational framework
68
Problem vs. Systems List
Choose problems or systems based on• Patient complexity• Patient settings• Institutional culture
Use caution for systems-based approach• Don’t lose sight of active, high-priority
issues by including all systems Use caution for problem-based
approach• Don’t forget to monitor all systems
69
Plan Section Develops specific plan
for each problem or diagnosis
Uses appropriate organizational framework
Reflects global plan for entire hospital stay• Avoid “to-do” items for
next shift
Specifies “None” if no plan is required
70
Maintenance of Patient Summary
Updates problems/diagnoses and plans daily• Provides current assessments• Establishes diagnoses • Lists changes in treatment
plans
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Maintenance of Patient Summary
Retains reason for admission and events leading up to admission• Allows others to understand the
nuances of presentation• For new providers• Working diagnosis may be incorrect
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PATIENT SUMMARIES An Essential Clinical Skill
Requires • Structured approach• Practice• Feedback• Reinforcement with faculty review• Verbal – direct observation and feedback• Written – review and critique
73
Patient Summary Example 1
74
Photo courtesy of John Howard/Lifesize/Thinkstock
75
Patient Summary Exercise 1
Review the admission history and physical examination for the next five minutes.
Create a patient summary to include in the printed handoff document• Use bulleted format and word limit <
200• Summary statement• Events leading up to admission• Ongoing assessment by problems/diagnoses • Plan by problems/diagnoses
76
Patient Summary Exercise 1Summary Statement: AJ is a 4 year old male with history of ex 26-week gestation admitted with hypoxia and respiratory distress secondary to a left lower lobe pneumonia. In the ED was found to have a Na of 130, likely secondary to volume depletion versus SIADH. Events Leading Up to Admission:Two days PTA–cough and high grade feversDay of admission –worsening respiratory distressHospital Course
O2 increased to 2.5 L on arrival to the floorS/P fluid bolus in EDOngoing Assessment Plan LLL Pneumonia 1. Continue ampicillin
2. Wean O2 as tolerated
Hyponatremia 1. D5NS at maintenance2. Repeat electrolytes
Q8H
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Large Group Questions
Did they capture all of the essential elements?
Did the verbal handoff differ from your written patient summary?
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Patient Summary Exercise 2
You are the day intern leaving and need to handoff back to the night intern.
Based on the updated hospital course, compose a patient summary on the patient after 48 hours in the hospital.
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48 Hours LaterSummary Statement:AJ is a 4 year old male admitted two days ago with a left lower lobe pneumonia and resolving hyponatremia now with worsening respiratory distress and left sided effusion s/p chest tube placement today with resultant improvement in status. Hospital CourseLeft sided pleural effusion noted on CXR with decubitus filmsChest tube placed with improving clinical statusSerum sodium is normalOngoing Assessment PlanLLL Pneumonia 1. Continuing ampicillin and O2
• Complicated by empyema 2. Chest tube to low wall suction
3. Surgery following4. Repeat chest X-Ray in am
Hyponatremia 1. No further laboratory studies 81
High Quality Patient Summaries
Create a shared mental model Facilitate the transfer of
information and responsibility Transmit information concisely Describe unique features of the
patient’s presentation Use semantic qualifiers
82
Semantic Qualifiers Dichotomous qualifiers along an axis• Provide clarity • Enable clear communication of
representative clinical features
Examples
83
Make an Assessment Using Semantic Qualifiers
Swelling developed in both this child’s knees over a two day span.
Acute, polyarticular swelling of both knees
84
Image courtesy of Dana Toib, MD
Make an Assessment Using Semantic Qualifiers
Jane has bouts of upper abdominal pain over the past 6 months that come and go
Recurrent, intermittent epigastric pain
85
Photo courtesy of Stockbyte/Stockbyte/Thinkstock
Key Points
Effective patient summaries • Allow providers to create a
shared mental model• Are succinct and concise• Include semantic qualifiers
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Action List To do list Includes specific elements• Timeline• Level of priority• Clearly-assigned responsibility (if
not receiver)• Indication of completion
Needs to be up-to-date• If no action items anticipated, clearly specify “nothing to do”
88
Action List
To Do:
☐ Check respiratory exam now
☐ Monitor respiratory exam Q2h overnight
☐ Check pain scores Q4h
☐ Check ins and outs at midnight
☐ Follow up 6PM electrolytes
☐ Follow up blood culture results
89
90
Situation Awareness
“Know what is going on around you”• Status of
patients• Team members• Environment• Progress toward
team goals
“Know what’s going on with your patient”• Status of patient’s
disease process• Team members’ role
in this patient’s care• Environmental
factors• Progress toward
goals of hospitalization
Team level Patient level
91
Contingency Planning
Problem solving before things go wrong
“If this happens, then…”92
Photo courtesy of Photodisc/Photodisc/Thinkstock
Importance of Contingency Planning
Is critical for patient safety Provides the receiver with
specific instructions for what might go wrong
Ensures accepting team is prepared to • Anticipate changes in patient
status• Respond to potential events or
changes in status93
Effective Contingency Planning
Articulate what might go wrong Define the plan• List interventions that have/have not
worked• Consider code status• Identify resources and chain of command
Provide details based on receiver’s• Level of experience• Knowledge of disease process• Familiarity with service and/or patient
94
Additional ConsiderationsContingency Planning
Difficult family or psychosocial situations
Nursing and family concerns
95
For stable patients:
“I don’t anticipate that anything will go wrong.”
96
Contingency Planning: An Example
Points of Emphasis
Video example illustrated• Contingency planning• Synthesis by receiver
Contingency plans included• Events• Interventions• Notifications
97
Contingency PlanningExercise
Refer to the patient summary you wrote about AJ, the 4 year old ex-premie, admitted with pneumonia and hyponatremia
Discuss with a partner for 1 minute• What contingency plans would you
recommend for this patient at the time of the handoff after admission?
(before complication of the effusion) Report back to large group
98
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Key Points
Situation awareness involves knowing what is going on around you
Effective contingency planning prepares for potential events or outcomes with specific instructions
100
101
Importance of Synthesis by Receiver
Provides brief re-statement of essential information in a cogent summary• Demonstrates information is
received and understood• Includes verbal and written
elements Ensures effective transfer of
information and responsibility Promotes a shared mental model
102
Synthesis by Receiver
Opportunity for receiver to• Clarify elements of handoff• Ensure there is a clear
understanding• Have an active role in handoff
process
103
Elements of Synthesis by Receiver
Vary in length and content• More complex, sicker patients require
more detail• At times may focus more on action
items, contingency planning Address priorities for individual
patients Affirm understanding by receiver
It is not a re-stating of entire verbal handoff!
104
I Illness SeverityP Patient SummaryA Action ListS Situation Awareness & Contingency PlanningS Synthesis by Receiver 105
Handoff Simulation Exercise
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Format I-PASS Handoff Simulation Exercise
Breakout large group Form groups of three with faculty
facilitator Practice handoffs with each of three
roles• Giver of handoff• Receiver of handoff• Observer of handoff• Complete Direct Observation Form
Debrief each handoff simulation• Faculty facilitator
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Putting It All TogetherI-PASS Handoff Bundle
108
Next Steps
I-PASS Handoff implementation• Today’s workshop• Complete workshop evaluation
• I-PASS Campaign launch• Real time• Observation• Feedback and reinforcement
109
Better handoffs. Safer care.
References"Agency for Healthcare Research and Quality. TeamSTEPPS Curriculum
Tools and Materials." http://www.ahrq.gov/. N.p., n.d. Web. 6 Feb 2012. http://teamstepps.ahrq.gov/abouttoolsmaterials.htm.
Bordage, G. "Prototypes and Semantic Qualifiers: From Past to Present." Medical Education. 41.12 (2007): 1117-21.
Cohen, M.D., and Hilligoss, P.B. "The Published Literature on Handoffs in Hospitals: Deficiencies Identified in an Extensive Review. " Quality and Safety in Health Care. 19.6 (2010): 493-497.
Kaplan, D.M. "Perspective: Whither the Problem List? Organ-Based Documentation and Deficient Synthesis by Medical Trainees." Academic Medicine. 85.10 (2010): 1578-1582.
Solomon, B. A., and Felder, R.M. "Index of Learning Styles Questionnaire." North Carolina State University. N.p., 2011. Web. 6 Feb 2012. http://www.engr.ncsu.edu/learningstyles/ilsweb.html.
Starmer, A.J., Spector, N.D., Srivastava, R., Allen, A.D., Landrigan, C.P., Sectish, T.C. et al. "I-PASS, a Mnemonic to Standardize Verbal Handoffs." Pediatrics. 129.2 (2012): 201-204.
Starmer, A.J., Sectish, T.C., Simon, D., and Landrigan, C.P. "Impact of a Resident Handoff Bundle on Medical Error Rates and Written Handoff Miscommunications." Pediatric Academic Societies Annual Meeting. Denver, CO. 2011.
111
Media Sources Media courtesy of the National Capital Consortium
Pediatric Residency Program, Bethesda, MD with input from the I-PASS Education Executive Committee, Simulation Subcommittee, Faculty Development Subcommittee, Campaign Subcommittee, and the Coordinating Council
The IIPE logo is used with permission from the Initiative for Innovation in Pediatric Education
The PRIS logo is used with permission from the Pediatric Research in Inpatient Settings Network
Some content in the I-PASS Handoff Study Curriculum includes materials adapted from TeamSTEPPSTM, an evidence-based teamwork curriculum developed by the Agency for Healthcare Research and Quality and the Department of Defense. All materials are used with permission.
All graphics are provide courtesy of Concurrent Technologies Corporation unless otherwise noted
112
ContributorsI-PASS Study Group
Lead Editors: April Allen MPA, MA, Theodore C.
Sectish MD, Nancy Spector MD, Amy Starmer MD
Additional Editors: Jennifer O’Toole MD, Clifton Yu MD, Lisa Tse
I-PASS Study LeadershipI-PASS Study PI: Christopher P. Landrigan MD, MPHI-PASS Project Leader: Amy J. Starmer MD, MPHI-PASS Coordinating Council: April D. Allen MPA, MA, Jaime Blank CCRP, Christopher P. Landrigan MD, MPH, Theodore C. Sectish MD, Nancy D. Spector MD, Rajendu Srivastava MD, MPH, Amy J. Starmer MD, MPH
113
Contributors
Membership of Additional I-PASS Committees Include: I-PASS Education Executive Committee (EEC) Co-chairs: Nancy D. Spector MD, Amy J. Starmer MD, MPH
I-PASS EEC: April D. Allen MPA, MA, James F. Bale Jr. MD, Zia Bismilla MD, Sharon Calaman MD, Maitreya Coffey MD, F. Sessions Cole MD, Lauren Destino MD, Jennifer Everhart MD, Jennifer Hepps MD, Madelyn Kahana MD, Christopher P. Landrigan MD, MPH, Joseph O. Lopreiato MD, Robert S. McGregor MD, Jennifer K. O’Toole MD, Shilpa J. Patel MD, Glenn Rosenbluth MD, Theodore C. Sectish MD, Nancy D. Spector MD, Rajendu Srivastava MD, MPH, Amy J. Starmer MD, MPH, Adam Stevenson MD, John Webster MD, MBA, Daniel C. West MD, Clifton E. Yu MD
Contributors I-PASS EEC Campaign Subcommittee: Glenn Rosenbluth MD (Chair),
April D. Allen MPA, MA, Sharon Calaman MD, Lauren Destino MD, Jennifer Everhart MD, Jennifer Hepps MD, Christopher P. Landrigan MD, MPH, Jennifer K. O’Toole MD, Shilpa J. Patel MD, Theodore C. Sectish MD, Nancy D. Spector MD, Amy J. Starmer MD, MPH, Adam Stevenson, Clifton F. Yu MD
I-PASS Faculty Development Subcommittee: Jennifer K. O’Toole (Co-chair), Nancy D. Spector MD (Co-chair), April D. Allen, MPA, MA, Glenn Rosenbluth MD, Theodore C. Sectish MD, Amy J. Starmer MD, MPH, Daniel C. West, Clifton E. Yu MD
I-PASS EEC Simulation Subcommittee: Sharon Calaman, MD (Chair), Jennifer Hepps MD, Joseph O. Lopreiato MD, MPH, Robert McGregor MD, Clifton E. Yu MD
I-PASS Scientific Oversight Committee: Christopher P. Landrigan MD, MPH, Sanjay Mahant MD, MSc, Theodore C. Sectish MD, Nancy D. Spector MD, Rajendu Srivastava MD, MPH, Amy J. Starmer MD, MPH, Karen M. Wilson, MD, MPH, Daniel C. West, MD
115
Participating I-PASS Institutions
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Children’s Hospital Boston / Harvard Medical School (Coordinating Site) Brigham and Women’s Hospital / Harvard Medical School (Data
Coordinating Center) Benioff Children’s Hospital / University of California San Francisco
School of Medicine Cincinnati Children’s Hospital Medical Center / University of Cincinnati
College of Medicine Doernbecher Children’s Hospital / Oregon Health & Science University
School of Medicine Hospital for Sick Children / University of Toronto Lucile Packard Children’s Hospital / Stanford University School of
Medicine National Capital Consortium / Uniformed Services University of the
Health Sciences Primary Children’s Medical Center / Intermountain Healthcare /
University of Utah School of Medicine St. Christopher’s Hospital for Children / Drexel University College of
Medicine St. Louis Children’s Hospital / Washington University School of Medicine
Funding and Resources
The I-PASS project is supported by Grant Number R18AE000029 from the U.S. Department of Health and Human Services. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Department of Health and Human Services.
The Pediatric Research in Inpatient Settings (PRIS) Network and the Initiative for Innovation in Pediatrics Education (IIPE) contributed to the management and oversight of the I-PASS Study.
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VERSION 4.0
© 2011 I-PASS Study Group/Children’s Hospital Boston. All rights reserved. For
permissions, contact [email protected].
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Better handoffs. Safer care.