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

July 12, 2011               Psst! Pass it on…How a kid’s game can mold good handoffs

July 19, 2011               Communication Across Professions

November 2011           Restricted Housestaff Work Hours and Patient Handoffs

December 2011            AORN Perioperative Handoff Toolkit

February 14, 2012       Handoffs – More Than Battle of the Mnemonics

March 2012                 More on Perioperative Handoffs

June 2012                    I-PASS Results and Resources Now Available

August 2012               New Joint Commission Tools for Improving Handoffs

August 2012                Review of Postoperative Handoffs

January 29, 2013         A Flurry of Activity on Handoffs

December 10, 2013     Better Handoffs, Better Results

February 11, 2014       Another Perioperative Handoff Tool: SWITCH

March 2014                  The “Reverse” Perioperative Handoff: ICU to OR

September 9, 2014      The Handback

December 2014            I-PASS Passes the Test

January 6, 2015            Yet Another Handoff: The Intraoperative Handoff

March 2017                 Adding Structure to Multidisciplinary Rounds

August 22, 2017         OR to ICU Handoff Success







TJC (The Joint Commission). Inadequate hand-off communication. Sentinel Event Alert 2017; 58: 1-6 September 12, 2017






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