Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

October 2017

Joint Commission Sentinel Event Alert on Handoffs

One of our most frequent topics has been handoffs in healthcare or other industries (see the full list of prior columns at the end of today’s column). Communication breakdowns are involved in over 75% of serious patient adverse events and transitions of care are particularly vulnerable to such communication breakdowns. Hence, optimal performance of handoffs is of utmost importance in preventing errors at such transitions.

The Joint Commission recently published a Sentinel Even Alert on faulty handoffs (TJC 2017). Much of the content was based upon The Joint Commission Center for Transforming Healthcare’s Hand-off Communications Project. That project involved 10 hospitals that used the Robust Process Improvement® (RPI®) and its Targeted Solutions Tool® (TST®) for Hand-off Communications to identity the root causes of and solutions to the problem of inadequate hand-offs. The Sentinel Event Alert illustrates how one hospital reduced its ineffective hand-offs by almost 60 percent while reducing the number of adverse events related to hand-off communication, using the TST® tool. It also discusses the I-PASS program, which we’ve written about extensively.

The Sentinel Even Alert emphasizes the need for leadership to prioritize a systemic approach to handoffs and provide appropriate resources for such. It recommends that content of handoffs be standardized and standardized tools (forms, templates, checklists, protocols, mnemonics, etc.) should be used. It notes that mnemonics (like I-PASS) may be helpful in guiding handoffs but the training and culture are critical to effective handoffs. Content should be in both verbal and written form and handoffs preferably should be face-to-face, with ample time and opportunities to ask questions. Locations for conducting handoffs should be free from interruptions, and include multidisciplinary team members and the patient and family, as appropriate. It lists various items and parameters that should be part of handoffs. While it stresses the face-to-face communication, it does recognize that the electronic medical record and other technologies may be used to enhance the handoff process.

Importance should be placed on training in conducting handoffs, using tools like real-time observation and performance feedback, role-playing and simulation, use of champions and coaches, and independent learning.

It also stresses that you need to have some way of measuring and monitoring the success of handoffs and the impact on adverse events.

The Sentinel Event Alert is well referenced and has good recommendations. While it emphasizes standardizing content and tools, we don’t think they are suggesting that the same content and tools be used for all handoffs across the organization. In our many columns listed below we have emphasized that the content and format of handoffs may differ based upon the type of transition of care occurring.

Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:

May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”

May 22, 2007 “More on TeamSTEPPS™”

August 28, 2007 “Lessons Learned from Transportation Accidents”

December 11, 2007 “Communication…Communication…Communication”

February 26, 2008 “Nightmares….The Hospital at Night”

September 30, 2008 “Hot Topic: Handoffs”

November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”

December 2008 “Another Good Paper on Handoffs”.

June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”

April 25, 2009 “Interruptions, Distractions, Inattention…Oops!”

April 13, 2010 “Update on Handoffs”