Impact of the I-PASS Communication Method on Nurse Handover Quality in Hospital Settings: A Scoping Review
Keywords:
Communication, Handover Quality, I-PASS method, Nurse, Patient safetyAbstract
Effective handover communication is a crucial element in ensuring patient safety and continuity of care in clinical settings. Communication errors during handovers frequently lead to medical errors and adverse events. The I-PASS method was developed as a structured solution to address these challenges. This study aims to identify and synthesize evidence regarding the impact of implementing the I-PASS communication method on the quality of nurse handovers and its contribution to improving patient safety. A comprehensive literature search was conducted across four major databases (Science Direct, EBSCO, PubMed, and Scopus) from December 2024 to September 2025, using keywords such as "Nurse”, "I-PASS Method," "Communication”, “Quality Handover” and "Patient Safety". Nine articles met the inclusion criteria, comprising quantitative, prospective, observational, and quasi-experimental studies published in English between 2015-2025. A total of 9 studies were included in this review. This study found five themes of impact I-PASS communication methods on the quality of nurse handovers. The implementation of I-PASS was associated with reduction in communication errors, improvement information quality, medical staff satisfaction, time efficiency, as well as patient and family engagement. While the effectiveness of I-PASS has been demonstrated across various contexts, implementation challenges such as environmental interruptions and the need for managerial support remain.
Downloads
References
Galatzan BJ, Carrington JM. Exploring the State of the Science of the Nursing Hand-off Communication. Computers, informatics, nursing : CIN. 2018 Oct;36(10):484–93. doi:10.1097/CIN.0000000000000461 PubMed PMID: 30045130.
Fernanda Y. Pelaksaan Overan Keperawatan Menggunakan Teknik Komunikasi SBAR di Ruangan Azzahrawi Rumah Sakit Ibnu Sina Yarsi Bukittinggi Tahun 2019. Doctoral dissertation, UNIVERSITAS PERINTIS INDONESIA. 2019;4(1):75–84.
Guttman OT, Lazzara EH, Keebler JR, Webster KLW, Gisick LM, Baker AL. Dissecting Communication Barriers in Healthcare: A Path to Enhancing Communication Resiliency, Reliability, and Patient Safety. Journal of Patient Safety. 2021;17(8).
Rosenthal JL, Doiron R, Haynes SC, Daniels B, Li STT. The Effectiveness of Standardized Handoff Tool Interventions During Inter- and Intra-facility Care Transitions on Patient-Related Outcomes: A Systematic Review. American Journal of Medical Quality. 2018;33(2):193–206. doi:10.1177/1062860617708244 PubMed PMID: 28467104.
Trinesa, D., Arif, Y., & Murni D. Faktor–Faktor Yang Berhubungan Dengan Pelaksanaan Handover Perawat. Endurance: Kajian Ilmiah Problema Kesehatan. 2020;5 (3):448--457.
Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, et al. Changes in Medical Errors after Implementation of a Handoff Program. New England Journal of Medicine. 2014;371(19):1803–12. doi:10.1056/nejmsa1405556 PubMed PMID: 25372088.
Streeter AR, Harrington NG. Erratum to “ Nurse Handoff Communication” [Seminars in Oncology Nursing Volume 33, Issue 5, December 2017, Pages 536–543] (S0749208117301043) (10.1016/j.soncn.2017.10.002)). Seminars in Oncology Nursing. 2018;34(1):116. doi:10.1016/j.soncn.2017.12.008 PubMed PMID: 29310848.
Hastuti EP, Faridah I, Afiyanti Y. Handover, Perbandingan Sbar, Model Terhadap, D A N I-pass. Jurnal Health Sains. 2021;2(3):301–9.
Starmer AJ, Spector ND, West DC, Srivastava R, Sectish TC, Landrigan CP. Integrating Research, Quality Improvement, and Medical Education for Better Handoffs and Safer Care: Disseminating, Adapting, and Implementing the I-PASS Program. Joint Commission Journal on Quality and Patient Safety. 2017;43(7):319–29. doi:10.1016/j.jcjq.2017.04.001
Joint Comission. Sentinel Event Statistics Data - Root Causes by Event Type (2004 - 2015). 2017. p. 1–29.
Syamsuriansyah S, Hizriansyah H. Health Information Quality and Patient Safety Performance: A Study at Awet Muda Narmada Regional Hospital. Journal of Health and Nutrition Research. 2025 Apr 21;4(1 SE-Articles):102–15. doi:10.56303/jhnresearch.v4i1.352
Omidi A, Rajabalipour MR, Arab S, Mokhtari Sorkhani T. Assessment of the I-PASS program on nursing shift handover in CCU and ICU wards: The use of a new approach in the nursing profession. Journal of Research Development in Nursing and Midwifery. 2023;20(2):1–4. doi:10.29252/jgbfnm.20.2.1
Azmi N, Prawesti Priambodo A, Nuraeni A. Analysis of Handoff Communication Using SBAR (Situation, Background, Assessment, Recommendation) in Emergency Department and Intensive Care Unit: A Scoping Review. Journal of Health and Nutrition Research. 2025 Aug 1;4(2 SE-Articles):464–73. doi:10.56303/jhnresearch.v4i2.400
Caruso TJ, Marquez JLS, Gipp MS, Kelleher SP, Sharek PJ. Standardized ICU to OR handoff increases communication without delaying surgery. International Journal of Health Care Quality Assurance. 2017;30(4):304–11. doi:10.1108/IJHCQA-02-2016-0015
Thornsberry L. Improving Nurse-to-Nurse Handoff Communication at the Bedside through Simulation-Based. 2019.
Riesenberg LA, Leisch J, Cunningham JM. Nursing handoffs: A systematic review of the literature. American Journal of Nursing. 2010;110(4):24–34. doi:10.1097/01.NAJ.0000370154.79857.09 PubMed PMID: 20335686.
Clements K. High-reliability and the I-PASS communication tool. Nursing Management. 2017;48(3):12–3. doi:10.1097/01.NUMA.0000512897.68425.e5
Shahian D. I- PASS handover system : a decade of evidence demands action. 2021;769–74. doi:10.1136/bmjqs-2021-013314
Starmer AJ, Schnock KO, Lyons AC, Hehn RS, Graham DA, Keohane CA, et al. Effects of the I-PASS Nursing Handoff Bundle on communication quality and workflow. BMJ Quality and Safety. 2017;26(12):949–57. doi:10.1136/bmjqs-2016-006224
Shekelle, P. G., Motala, A., & Lawson E. Use of structured handoff protocols for intrahospital within-unit transitions (Making Healthcare Safer IV Rapid Review, AHRQ Publication No. 25-EHC008-2). Agency for Healthcare Research and Quality. 2025. doi:https://doi.org/10.23970/AHRQEPC_MHS4HANDOFF
Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005 Feb 1;8(1):19–32. doi:10.1080/1364557032000119616
Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of internal medicine. 2018 Oct;169(7):467–73. doi:10.7326/M18-0850 PubMed PMID: 30178033.
Cardona-Morrell M, Prgomet M, Lake R, Nicholson M, Harrison R, Long J, et al. Vital signs monitoring and nurse–patient interaction: A qualitative observational study of hospital practice. International Journal of Nursing Studies. 2016;56:9–16. doi:https://doi.org/10.1016/j.ijnurstu.2015.12.007
Ait Aiss M, Vesho D, Bowe C, Franco-Vega MC, Chau S, Beno J, et al. Using I-PASS to improve nursing handoffs across the continuum of care at a tertiary oncology hospital. BMJ Open Quality. 2025;14(3). doi:10.1136/bmjoq-2025-003443
Chladek MS, Doughty CB, Patel B, Alade KH, Rus MC, Shook JE, et al. The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS. BMJ Open Quality. 2021;10(3). doi:10.1136/bmjoq-2020-001254
Lafontaine J, Casacalenda N, Perreault M, Laliberté V, Milton D. Improving Transfer of Care Between Psychiatrists and Residents: Participants’ Perspective on the Implementation of a Handover Protocol in a Psychiatric Emergency. Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry. 2022 Feb;46(1):114–9. doi:10.1007/s40596-021-01472-5 PubMed PMID: 33973167.
Abt M, Schneider P, Martin L, Delmas P, Ortoleva Bucher C. I-PASS-Structured Bedside Nursing Handovers: A Type-1 Effectiveness—Implementation Hybrid Pilot Study. Journal of Advanced Nursing. 2025. doi:10.1111/jan.16896
Omar I, Miller K, Madhok B, Amr B, Singhal R, Graham Y, et al. The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery. International Journal of Surgery. 2022;104:106766. doi:https://doi.org/10.1016/j.ijsu.2022.106766
Blazin LJ, Sitthi-amorn J, Hoffman JM. Improving Patient Handoffs and Transitions through Adaptation and Implementation of I-PASS Across Multiple Handoff Settings. Vol. 5. 5(4). doi:10.1097/pq9.0000000000000323
Starmer AJ, Spector ND, O’Toole JK, Bismilla Z, Calaman S, Campos ML, et al. Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. Journal of Hospital Medicine. 2023;18(1):5–14. doi:10.1002/jhm.12979
Miller D. I-PASS as a Nursing Communication Tool. Pediatric Nursing. 2021;47(1):30–7. doi:10.62116/pnj.2021.47.1.30
Khedkar A, Desai SA, Nanavati RN. Implementation of a structured handover in the Nicu. Perinatology. 2021;22(2):114–22.
Ransom B, Winters KP. The I-PASS mnemonic and the occurrence of handoff related errors in adult acute care hospitals: a systematic review protocol. JBI Database of Systematic Reviews and Implementation Reports. 2018;16(1):21–6. doi:10.11124/JBISRIR-2016-003303
Soares DRA, Rodrigues D, Carmona F. Implementation of a standardized handoff system (I-PASS) in a tertiary care pediatric hospital; Implementação de um sistema padronizado de passagem de plantão (I-PASS) em um hospital terciário pediátrico. Revista Paulista de Pediatria. 2023;41. doi:10.1590/1984-0462/2023/41/2022123
Stenquist DS, Yeung CM, Szapary HJ, Rossi LP, Chen AF, Harris MB. Sustained Improvement in Quality of Patient Handoffs After Orthopaedic Surgery I-PASS Intervention. Journal of the American Academy of Orthopaedic Surgeons Global Research and Reviews. 2022;6(9). doi:10.5435/JAAOSGlobal-D-22-00079
Franco-Vega MC, Ait Aiss M, George MC, Day L, Mbadugha A, Owens K, et al. Enhancing Implementation of the I-PASS Handoff Tool Using a Provider Handoff Task Force at a Comprehensive Cancer Center. Joint Commission Journal on Quality and Patient Safety. 2024;50(8):560–8. doi:10.1016/j.jcjq.2024.03.004
Walia J, Qayumi ZS, Khawar N, Dygulska B, Bialik I, Salafia CM, et al. Physician Transition of Care: Benefits of I-PASS and an Electronic Handoff System in a Community Pediatric Residency Program. Academic Pediatrics. 2016;16(6):519–23. doi:10.1016/j.acap.2016.04.001
Skaret MM. Automation of the I-PASS Tool to Improve Transitions of Care. Vol. 41. 2019;41(5). doi:10.1097/JHQ.0000000000000174
Sweller J. Cognitive Load During Problem Solving : Effects on Learning. Vol. 285. 1988;285:257–85. doi:10.1207/s15516709cog1202
Morris KY, Jakobsen R. Central venous catheter access and procedure compliance: A qualitative interview study exploring intensive care nurses’ experiences. Intensive and Critical Care Nursing. 2022;69:103182. doi:https://doi.org/10.1016/j.iccn.2021.103182
Starmer AJ, O’Toole JK, Rosenbluth G, Calaman S, Balmer DF, West DC, et al. Development, implementation, and dissemination of the I-PASS handoff curriculum: A multisite educational intervention to improve patient handoffs. Academic Medicine. 2014;89(6):876–84. doi:10.1097/ACM.0000000000000264
Rizzo JR, House RJ, Lirtzman SI. Role Conflict and Ambiguity in Complex Organizations. Vol. 15. 2013;15(2):150–63.
Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Archives of Internal Medicine. 2012 Oct 8;172(18):1377–85. doi:10.1001/archinternmed.2012.3199
Hall LH, Johnson J, Watt I, Tsipa A, Connor DBO. Healthcare Staff Wellbeing , Burnout , and Patient Safety : A Systematic Review. 2016;1–12. doi:10.1371/journal.pone.0159015
Weick KE, Sutcliffe KM. Managing the unexpected: Resilient performance in the age of uncertainty, 2nd ed. Managing the unexpected: Resilient performance in the age of uncertainty, 2nd ed. Hoboken, NJ, US: Jossey-Bass/Wiley; 2007. xii, 194–xii, 194 p.
Published
How to Cite
Issue
Section
Copyright (c) 2026 Agnes Stephania Penu, Ati Surya Mediawati, Hana Rizmadewi Agustina
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Most read articles by the same author(s)
- Nirmala Sunati, Maria Komariah, Hana Rizmadewi Agustina, Factors Influencing Nurse Job satisfaction and the Consequent Effects on Patient Care Quality: A Scoping Review , Journal of Health and Nutrition Research: Vol. 4 No. 3 (2025)
