Mnemonic Device Mitigates Medical Errors

medical_errors    A recent, multi-institutional study evaluated changes in medical errors at nine pediatric residency training programs after implementation of a robust handoff training curriculum.  The intervention included seven different elements focused on resident and faculty education centered on the I-PASS mnemonic.  I-PASS which stands for illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by reviewer has been established as an appropriate method of patient transmission in the pediatric community.  Two significant strengths of the study include: 1) oral and written components of the training and 2) time period assessed for curriculum effectiveness accounted for resident experience.  The authors noted, “A significant reduction in overall medical error rates (24.5 vs. 18.8 errors per admission, p<0.001) and a 30% relative reduction in rate of preventable adverse events (4.7 vs. 3.3 events per 100 admissions, p<0.001)”.  The evidence in this study is highly suggestive that implementation of the I-PASS bundle curriculum intervention is a valuable tool to improve patient safety and reduce medical errors in the pediatric world. – Archana Pradhan, MD


Link To Article


Amy J. Starmer, M.D., M.P.H., Nancy D. Spector, M.D., et al, for the I-PASS Study Group, Changes in Medical Errors after Implementation of a Handoff Program N Engl J Med 2014; 371:1803-1812
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