On-Demand Learning Lab: Implementing Structured Handoffs to Achieve High Reliability-Recording - Implementing Structured Handoffs to Achieve High Reliability

Video Transcription

Video Summary

NACU hosted a Live Learning Lab webinar on “Implementing Structured Handoffs to Achieve High Reliability,” featuring Marshall Burkhart (I-PASS Patient Safety Institute) and Dr. Christopher Landrigan (Boston Children’s Hospital/Harvard), a longtime patient safety researcher and leader of the I-PASS study group. The presenters framed the ongoing national challenge of patient harm from medical errors and highlighted that communication failures remain a top root cause of sentinel events and adverse outcomes.<br /><br />They described how frequent shift changes exposed wide variability in handoffs, prompting development of the I-PASS structured handoff mnemonic: Illness severity, Patient summary, Action list, Situation awareness/contingency planning, and Synthesis by receiver (closed-loop communication). Beyond the mnemonic, they emphasized implementation essentials: training, practice/simulation, auditing and feedback, EHR-supported written tools, data visibility, and leadership support to drive culture change.<br /><br />Evidence from multicenter studies showed I-PASS improves handoff content and reduces harm—about 30% fewer preventable adverse events in early pediatric studies, with later broader implementations achieving higher adherence and larger harm reductions. Additional reported benefits included fewer callbacks, shorter sign-outs, reduced nursing overtime, improved bedside shift reporting, and potential malpractice cost impact. The I-PASS Institute now focuses on scalable, mentored implementation using digital training, EHR-integrated tools, and auditing supports.

Keywords

NACU Live Learning Lab webinar

structured handoffs

high reliability healthcare

I-PASS mnemonic

patient safety medical errors

communication failures sentinel events

closed-loop communication synthesis by receiver

handoff training simulation auditing feedback

EHR-integrated handoff tools