Dear potential I-PASS investors and supporters,
For decades, the healthcare community has known that medical errors are a major problem in our hospitals. Far too many patients die or are harmed as a consequence of care they receive, despite the best intentions of their doctors and nurses. Miscommunications are a leading cause of these harms, particularly during “handoffs” at change of shift or when a patient changes locations in the hospital. At an average sized U.S. hospital, there are approximately 1.6 million handoffs every year. We developed I-PASS, a multi-faceted handoff improvement program, to fix this problem.
Over the past nearly 10 years, I have had the honor of working with the five physician co-founders of the I-PASS Patient Safety Institute, as well as over 150 physicians, nurses, family advocates, and others to carry out a series of studies to look at what happened when we put I-PASS into practice. Since we started I-PASS in 2008, the program has been extensively refined, tested and adapted, and well-integrated into doctors’ and nurses’ workflow patterns.
With the support of over $7 million in federal and foundation grants, we found in our first major study that implementing I-PASS led to a 30% reduction across 9 hospitals in injuries due to medical errors, and in subsequent studies found similar benefits in a diverse group of 35 adult and pediatric hospitals across the country. I-PASS leads to improvements in handoffs for physicians and nurses. It works across specialties, in academic and community hospitals alike. Additional research into this topic has found that an estimated 80 percent of the most serious medical errors in hospitals can be linked to communication failures, particularly during patient handoffs.
My interest in handoffs began early in my career, during my medical residency and fellowship. I trained in the late 1990s, just as the healthcare community began to recognize the scope of the patient safety problem in our hospitals. I became interested initially in studying the effects of sleep deprivation on patient safety and performance, as I had personally struggled with the effects of a lack of sleep on my ability to provide appropriate care to my patients as a trainee. I learned very quickly that I was not alone in this struggle. I led studies documenting the effects of doctors’ sleep deprivation on patient safety, and advocated for policies to begin to move the profession towards safer work hours. Although we still have a long way to go on this front, we have begun to take some small steps forward. However, as I worked to eliminate the 24-hour and longer shifts that doctors have traditionally worked, it became apparent that a reduction of each work shift would translate to more shift changes and more handoffs. To support those shift changes, we needed to reduce the risk inherent in handoffs, and I-PASS was born.
It is extremely gratifying to see I-PASS beginning to spread, but we are truly just at the beginning. While we have managed to introduce the program in over 50 hospitals, there are nearly 5,000 hospitals in the U.S. alone. Even in the 50 hospitals where we have gotten I-PASS started, the program is for the most part being used in only a couple of units or departments. Grants and an academic approach to the problem were crucial for getting started, but in order to scale the program so that it has a real impact on the safety of the healthcare system, we need to work differently.
The I-PASS Patient Safety Institute was created to meet this tremendous need. The Institute has now been in existence for just over one year, and in that time we have developed a series of product offerings that are allowing us to take the key elements of I-PASS – an interactive handoff training program, modification of oral and written handoff processes in hospitals, and tracking, reinforcement, and iterative improvement of those processes over time – and scale them for hospital-wide application. We have been working intensively with several hospitals to test the initial commercial release of our products and have been tuning our related professional service offerings that leverage the nearly 10 years of research that we have put into I-PASS.
The feedback that the I-PASS Patient Safety Institute has received on the applicability and usability of our products has been extremely positive, and we believe that our product and service offerings will be able to help large numbers of hospitals achieve their goal of improving patient safety, while having the added benefit of driving down costs that are associated with medical errors (including the costs of care associated with medical errors and medical malpractice claims).
In closing, I want to thank you for spending your valuable time to understand more about I-PASS and the I-PASS Patient Safety Institute. We hope that you share our passion for patient safety. We would be honored to have you become a part of the I-PASS family.
Thank you for considering joining us,
Christopher P. Landrigan, MD, MPH
Principal Investigator, I-PASS Study Group
Co-Founder and Board Member, I-PASS Patient Safety Institute