Inadequate hand-off communication.
Approach to Improving Safety
Setting of Care
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.