In hospitals or larger clinics, the risks of errors in “hand-offs” from one provider to another are well-known. Examples are changes of shifts for nurses or hospitalists, when mistakes are made in providing information about the patients whose care is being transferred. Sometimes those information errors are then passed on to the next shift or provider taking over care of the patient.

A recent study by the New England Journal of Medicine, in which the Oregon Health & Science University participated, identified specific errors and came up with a program to reduce such errors. The findings of the study were that miscommunication is a leading cause of serious medical errors, and that improvements in communications can decrease such errors by significant amount.

The solution proposed by the study is called “I-PASS.” It calls for standardized communication rules for verbal handoffs, and computerized tools for sharing patient information. The challenge was to make the handoff process more accurate, but without increasing the time involved in the process. The study found that, with training in using the new system, significant errors that could have led to patient injury were reduced by 23-30%.