Improving Safety of Written Sign-out in an Internal Medicine Residency Program Using I-PASS

From the 2022 HVPA National Conference

John Gaskill DO (Cleveland Clinic Foundation), Jenna Carson MD, Aidan Neustadtl MD, Jiafei Niu DO, Nivaas Thanoo MD, Gretchen Santana Cepero MD


Patient handoffs are a critical time to ensure patient safety. Approximately two-thirds of sentinel events in the hospital are attributed to communication errors, with about half of those occurring during handoffs (1). To reduce communication errors, there has been increased emphasis on standardizing handoffs. I-PASS, an easy to remember mnemonic, is the gold standard for handoff communication as it reduces medical errors (1,2). The five components of I-PASS are illness severity, patient summary, action list, situational awareness and contingency planning, and synthesis by receiver (1).

One component of handoff is written signout. At our internal medicine residency program, written signout is produced through a secure electronic system that is manually updated by residents. Though residents receive training in verbal handoff, there is no teaching on or standardization of written signout. At baseline, only 2.5% of sampled written signouts included all of the I-PASS components.


Increase the percentage of patients on the internal medicine teaching services with accurate I-PASS components on written signout by 50% by June 2022.


This quality improvement project was conducted across eight teaching services within the Cleveland Clinic Internal Medicine Residency Program between September 2021 and April 2022. Interventions included a peer-to-peer education session, weekly reminders about I-PASS, and the creation of standardized template signout templates documents. We also surveyed residents regarding perceived accuracy of signout and satisfaction with the current system.


Prior to any intervention, the percentage of written signouts that included all four components of I-PASS was 2.5%. Following our peer-to-peer education intervention the percentage of patients with all components of I-PASS was 0% and following the creation of a standardized template the percentage was 3.125% (p>0.05). Similarly, in our secondary outcomes there were no significant changes in the percentage of patients with accurate medication lists, presence of vital signs or lab values, and accurate code status. Review of survey data revealed that only 28% of day team residents and 33% of night team residents were satisfied with the current signout system.


This study highlights a critical opportunity to ensure patient safety by improving the thoroughness and accuracy of written sign-out, however, our interventions have so far not proven effective.

Clinical Implications

A stronger emphasis must be placed on written sign-out at the time of handoffs to prevent communication errors.


Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC; I-PASS Study Group. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics. 2012 Feb;129(2):201-4. doi: 10.1542/peds.2011-2966. Epub 2012 Jan 9. PMID: 22232313.

Fryman C, Hamo C, Raghavan S, Goolsarran N. A Quality Improvement Approach to Standardization and Sustainability of the Hand-off Process. BMJ Qual Improv Rep. 2017 Apr 6;6(1):u222156.w8291. doi: 10.1136/bmjquality.u222156.w8291. PMID: 28469889; PMCID: PMC5387931.

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