(HealthDay News) — Changing how doctors communicate during shift changes in hospitals reduces the risk for adverse events in patients by 30%, according to a study published in the Nov. 6 issue of the New England Journal of Medicine.

In a study of 10,740 patients, Amy Starmer, MD, MPH, of the Harvard Medical School in Boston, and colleagues found that a better method of communication reduced the rate of medical errors by 23% and the rate of preventable adverse events by 30%. 

To improve communication between doctors caring for patients, Starmer’s team instituted a “handoff” program at nine hospitals. The study authors measured how effective the program was in reducing medical errors and adverse events in patients. They also looked to see if the program interfered with workflow.

Specifically, they developed a method of communication dubbed the “I-PASS Handoff Bundle.” For each patient in the doctor’s charge, both oral and written data are required to describe: I; Illness severity (the patient’s condition); P: Patient summary (what’s wrong with the patient and history); A: Action list (what needs to be done); S: Situation awareness and contingency planning (planning for what might happen); S: Synthesis by receiver (asking questions, showing the material was understood).

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Doctors were trained to use the system, as well as how to use it in conjunction with the electronic medical record system, Starmer told HealthDay. In addition to reducing medical errors, such as prescribing the wrong medications or procedures, the program didn’t take a toll on the doctors’ workflow. 

“We are really excited about the study,” Starmer said. “Not only do we see a dramatic reduction in medical errors, but we found that this method is adaptable to other hospitals and to other health care workers, such as nurses and surgeons.”


  1. Starmer AJ et al. N Engl J Med. 2014;371:1803-1812.