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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.

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.

This piece describes a framework for applying elements of professionalism to clinical teamwork policies to drive safer care coordination.

The introduction of health information technology (IT) has resulted in various documented improvements in patient safety and care delivery. However, unintended consequences have also emerged, and the potential for health IT to cause harm is now well recognized. This report includes 10 recommendations for research, policy, industry, and clinician users. These broad guidelines are aimed at coordinating diverse efforts from different stakeholder groups to improve the safe and effective use of health IT. Previously, a 2011 Institute of Medicine report and an online AHRQ guide made recommendations concerning safe implementation of electronic health records. A previous AHRQ WebM&M perspective examines the benefits and challenges of available health IT systems.

This revision of the 2010 committee statement describes important characteristics for tracking systems and patient reminders to prevent missed or delayed diagnoses.

This guideline outlines the basic elements of an effective patient handoff.

This consensus statement provides an evidence-based definition of critical diagnoses and suggests that each institution create its own policy for how to manage communication of diagnoses.

The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these recommendations is then assessed as part of Joint Commission accreditation surveys at health care organizations nationwide. This recently retired alert targets prevention of maternal death and highlights the need to manage blood pressure, pay attention to vital signs following cesarean delivery, and hemorrhage. The alert also provides recommendations around educational strategies, identifying specific clinical triggers for action, and conducting adequate risk assessments. As of September 2016, current guidance will be distributed by a new initiative. Please refer to the information link below for further details.

This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes.

Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission. Note: This alert has been retired effective October 2019. Please refer to the full-text link below for further information.

This guidance statement outlines recommendations from the Association of periOperative Registered Nurses (AORN) for developing, implementing, and evaluating safe medication practices in the perioperative environment.

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.