Does your hospital or medical center have tried-and-true processes for transferring patients to and from the operating room (OR)? If so, then there are no communication problems when the patient is handed off to your OR team—right? And, of course, there are no misunderstandings when your team hands the patient off to staff in recovery or the intensive care unit—correct?
These communications issues are bound to arise at most institutions. The latest Sentinel Event Alert, Issue 58, “Inadequate hand-off communication,” published by The Joint Commission, identifies actions providers can take to address handoff communication problems. It includes an infographic, “8 tips for high-quality hand-offs,” and provides advice to senders and receivers of handoff communication, including communication between caregivers within hospitals and other health care settings, and between hospital caregivers and non-hospital-based providers (see Figure 1).
Figure 1. 8 Tips for high-quality hand-offs
Handoffs and patient safety
Handoffs—also known as handovers—are real-time processes of conveying patient-specific information from one caregiver to another or from one team of caregivers to another to ensure the continuity and safety of patient care. Handoffs are complex, and a common issue with these situations is that expectations may be out of balance between the sender of the information and the receiver.1
Patient safety can be affected when the receiver gets information that is inaccurate, incomplete, not timely, misinterpreted, or irrelevant. Many factors contribute to handoff failure, such as the following:
- Health care provider training and expectations
- Language barriers
- Cultural or ethnic considerations
- Inadequate, incomplete, or nonexistent documentation
In 2006, The Joint Commission established a National Patient Safety Goal that addressed handoff communication. It became a standard in 2010. Provision of Care (PC) standard PC.02.02.01, element of performance 2, 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.”2
Handoffs happen frequently in health care, particularly in hospitals. A typical teaching hospital may experience more than 4,000 handoffs each day.3 The Joint Commission’s sentinel event database includes reports of inadequate handoff communication contributing to adverse events, including:
- Wrong site surgery
- Delay in treatment
- Medication errors
In addition, a 2016 study estimated communication failures in U.S. hospitals and medical practices were responsible for 30 percent of all medical liability claims, which resulted in 1,744 deaths and $1.7 billion in costs over a five-year period.4
Solutions to handoff miscommunication
The Joint Commission Center for Transforming Healthcare conducted a handoff communications study involving 10 hospitals that used robust process improvement to identity root causes of, and solutions to, inadequate handoffs. Receivers assessed that 37 percent of the handoffs were unsuccessful, and senders estimated that 21 percent of handoffs were unsuccessful.
The Joint Commission’s Targeted Solutions Tool (TST) for Hand-off Communications—to which Joint Commission-accredited organizations have free access—can assist in managing this quality improvement process. A study in the March 2016 issue of The Joint Commission Journal on Quality and Patient Safety found that after implementing the TST and its processes for resolving a hospital’s identified root causes, the rate of defective handoffs decreased by 58.2 percent.5
The Sentinel Event Alert lists critical information that should be communicated to the receiver during a handoff, including the following:6
- Sender contact information
- Illness assessment, including severity
- Patient summary, including events leading up to illness or admission, hospital course, ongoing assessment, and plan of care
- To-do action list
- Contingency plans
- Allergy list
- Code status
- Medication list
- Dated laboratory tests
- Dated vital signs
The Sentinel Event Alert also suggests that hospitals take the following actions to address handoff communication:
- Demonstrate leadership’s commitment to successful handoffs and other aspects of a safety culture.
- 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, and so on) to communicate to receivers.
- Conduct face-to-face handoff 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.
- Standardize training on how to conduct a successful handoff—from both the standpoint of the sender and receiver.
- Use electronic health record capabilities and other technologies—such as apps, patient portals, and telehealth—to enhance handoffs between senders and receivers.
- Monitor the success of interventions to improve handoff communication, and use the lessons to drive improvement.
- Sustain and spread best practices in handoffs, and make high-quality handoffs a cultural priority.
The Sentinel Event Alert can be viewed on The Joint Commission’s website.
The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.
- The Joint Commission Center for Transforming Healthcare. Improving transitions of care: Hand-off communications. Oakbrook Terrace, IL. 2014. Available at: www.centerfortransforminghealthcare.org/assets/4/6/handoff_comm_storyboard.pdf. Accessed October 31, 2017.
- The Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. Provision of Care, Treatment, and Services chapter. Oakbrook Terrace, IL. 2017 update. (Manual and corresponding updates are subscription-based.)
- Vidyarthi AR. Triple handoff. AHRQ Web M&M. September 2006. Available at: https://psnet.ahrq.gov/webmm/case/134. Accessed October 31, 2017.
- CRICO Strategies. Malpractice risks in communication failures. 2015 Annual Benchmarking Report. 2015. Available at: www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures (registration required for download). Accessed October 31, 2017.
- Benjamin MF, Hargrave S, Nether K. Using the Targeted Solutions Tool to improve emergency department handoffs in a community hospital. Jt Comm J Qual Patient Saf. 2016;42(3):107-118.
- Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implantation of a handoff program. N Engl J Med. 2014;371(19):1803-1812.