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Sentinel event alert. 2017;58:1-6.
The Joint Commission publishes sentinel event alerts to draw attention to pressing or emerging safety issues and provide guidelines for organizations on how to address them. This alert highlights potential safety hazards at the time of handoffs, defined as "a transfer and acceptance of patient care responsibility achieved through effective communication." Handoffs can occur within or across settings of care (e.g., between two clinicians in the same hospital or between a hospital and a long-term care facility). To ensure high-quality handoffs, the alert recommends that health care organizations take several actions, including providing handoff training to clinicians, engaging leadership in prioritizing handoffs as an essential part of a culture of safety, and using continuous improvement methodology to monitor and enhance handoffs. High-quality research has defined effective communication techniques for preventing handoff errors (such as the I-PASS mnemonic), and the alert specifically recommends use of these tools. A past WebM&M commentary discussed a handoff error that nearly resulted in serious patient harm.
Jewell JA. Pediatrics. 2016;138:e20162681.
Handoffs at shift changes are vulnerable to communication errors, which can result in patient harm. This guideline describes how to improve handoffs, including by standardizing content, dedicating certain locations and time periods to reduce interruptions, and using technological resources to augment accuracy of handoff information. A past PSNet perspective discussed safe inpatient handovers.
Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014).
In this hearing Veterans Affairs leadership provide an update on the current investigation into data and scheduling manipulation in the VA system. The testimonies discuss the scope of the problem, suggest that the culture at the hospitals enabled record falsification to become normalized, and outline actions being taken to address weaknesses in processes and access to care.
Sentinel Event Alert. 2006;35:1-4.
This alert emphasizes the importance of reconciling medications and supports implementation of this Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) National Patient Safety Goal. Note: This alert has been retired effective August 2016. Please refer to the information link below for further details.