Accreditation

Communication breakdown: Sentinel Event Alert calls out bad patient handoffs

Briefings on Accreditation and Quality, January 1, 2018

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In September, The Joint Commission published Sentinel Event Alert 58, warning healthcare organizations about the dangers of inadequate handoff communications. When a patient changes hands, there’s a big risk that key treatment information will be garbled, forgotten, or not passed on.

A patient handoff (also known as transitioning) constitutes both the act of passing a patient between caregivers and the information exchanged between the sender (i.e., the person giving away the patient) and the receiver (i.e., the person taking the patient). These transfers can be as dramatic as airlifting a patient to a specialty hospital and telling the EMTs that the patient thinks she can fly and will try to jump out of the helicopter, or as mundane as a nurse ending her shift and telling her replacement the patient has been taken off a certain medicine.

No matter how dramatic or anticlimactic handoffs may seem, they are crucial for a smooth care transition. Despite that, The Joint Commission has found they’re a continual weak point in healthcare.

“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,” The Joint Commission wrote in the alert. “When hand-off communication fails, many factors are involved, such as healthcare provider training and expectations, language barriers, cultural or ethnic considerations, and inadequate, incomplete or nonexistent documentation, to name just a few.”

Nan Tomsky, MN, RN, CPHRM, a principal consultant at Compass Clinical Consulting, explains that the information provided during a handoff is key in ensuring a seamless transition of patient care.

“Failure to properly transfer knowledge about the patient can result in serious outcomes when the receiving caregiver is ignorant of critical information,” she says. “Needed medications may be omitted, key symptoms/indications of patient changes can be missed, and patients can fall and suffer serious injuries among other outcomes.”

 

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