Tool: I-PASS
Problem: According to the Joint Commission, miscommunication as a leading cause of sentinel events. We sought to determine the proportion of medical-malpractice claims involving communication failure and describe their nature, including providers, locations, miscommunication types, costs, and potential for handoff tools to avert risk and associated costs.
Tool Selection: I-PASS implementation has been demonstrated in multiple prior studies to reduce medical errors. We sought to understand what impact I-PASS might have on rates of malpractice claims and associated costs.
Usage: We conducted a retrospective study of 500 randomly selected claims from a national database. Each claim was reviewed by physicians who determined if a miscommunication was involved, costs of the claim, and the potential role of I-PASS in averting a claim.Results:49% of claims involved miscommunications. Claims involving miscommunications were much more expensive than those that did not ($238,000 versus $154,000). I-PASS could have prevented a majority of those claims involving a failed handoff.
