The Joint Commission has issued Sentinel Event Alert (SEA) 58 focused on inadequate hand-off communication and its potential to result in adverse events, causing harm to patients.

According to the alert, “Inadequate hand-off communication is a contributing factor to adverse events, including many types of sentinel events. The Joint Commission’s sentinel event database includes reports of inadequate hand-off communication causing adverse events, including wrong-site surgery, delay in treatment, falls, and medication errors. A study released in 2016 estimated that communication failures in U.S. hospitals and medical practices were responsible at least in part for 30 percent of all malpractice claims, resulting in 1,744 deaths and $1.7 billion in malpractice costs over five years.”

Because communication is such a common problem during hand-off communication, TJC established PC.02.02.01 EP 2, which requires that: The organization’s process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information. Note: Such information may include the patient’s condition, care, treatment, medications, services, and any recent or anticipated changes to any of these.

Hand-off Communication and Patient Safety

The Joint Commission Center for Transforming Healthcare defines a handoff as the “real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another.” The purpose of hand-off communication is to ensure continuity and safety in patient care.

SEA 58 explains that “potential for patient harm – from the minor to the severe – is introduced when the receiver gets information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed.” Factors such as provider training, language barriers, and incomplete documentation can contribute to communication failures during patient handoffs.

How Healthcare Organizations Can Achieve Successful Handoffs

While inadequate hand-off communication has the potential to lead to patient harm, efforts and programs dedicated to successful patient handoffs can significantly improve patient safety. SEA 58 recommends the following actions for healthcare organizations:

  1. Demonstrate leadership’s commitment to successful hand-offs and other aspects of a safety culture.
  2. Standardize critical content to be communicated by the sender during a handoff – both verbally (preferably face to face) and in written form. Make sure to cover everything needed to safely care for the patient in a timely fashion. Standardize tools and methods (forms, templates, checklists, protocols, mnemonics, etc.) to communicate to receivers.
  3. Conduct face-to-face hand-off communication and sign-outs between senders and receivers in locations free from interruptions, and include multidisciplinary team members and the patient and family, as appropriate.
  4. Standardize training on how to conduct a successful hand-off – from both the standpoint of the sender and receiver.
  5. Use electronic health record (EHR) capabilities and other technologies — such as apps, patient portals and telehealth — to enhance hand-offs between senders and receivers.
  6. Monitor the success of interventions to improve hand-off communication, and use the lessons to drive improvement.
  7. Sustain and spread best practices in handoffs, and make high-quality hand-offs a cultural priority.

In addition, TJC has published an infographic of tips to help all care givers achieve successful hand-offs.

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