Starmer's I-PASS paper is in every published patient-safety syllabus by now. The headline: 30% reduction in preventable adverse events when nine pediatric residency programs implemented a standardised handoff bundle (NEJM, 2014).

What gets less attention is what changed between the pilot and the follow-up.

The I-PASS follow-up (Starmer et al., JAMA Pediatrics, 2017) showed that the gains held at one year, with continued reduction in errors. But it also showed that adherence to the structure decayed — by year-end, only about 65% of handovers were following the full I-PASS structure, down from 84% at the rollout's peak.

The patient-safety gains held despite the decay. The implication is that the structure trained the residents in how to think about handover, even when they stopped using the bundle to the letter. The structure became internalised.

This matters for tool design. If a tool tries to enforce I-PASS rigidly — with required fields, validation, refusing to submit incomplete handovers — it creates the same friction that the paper-based protocol created. Residents adapt by routing around the tool.

If a tool suggests the structure — by composing a draft in I-PASS format, that the resident can edit — the structure becomes the default but the resident retains the agency to adapt it for the case at hand. The I-PASS framework becomes a starting point rather than a checkbox exercise.

This is the design choice we made in Medows. The auto-composed handover follows I-PASS structure ("Now: …" and "Pending: …" for the most pressing two elements, with optional fields for illness severity and synthesis). The resident edits before sending. The structure is preserved without being enforced.

If you're rolling out I-PASS in your programme and finding the year-two decay starting to bite, the right intervention is not more enforcement. It is making the structured handover the path of least resistance.