The recently released Joint Commission Sentinel Event Alert Issue 58 emphasizes that communication failures are a major contributor to adverse events in the health care environment. The Alert provides hospitals and other health care settings with recommendations to help prevent communication failures when patients are transitioned from one caregiver (or team of caregivers) to another. The Alert also reviews factors contributing to such "hand-off communication" failures, solutions, research, quality improvement efforts, and related Joint Commission requirements.
"When a patient is handed off to another health care provider for continuing care, treatment, or services, the type of information the receiving provider needs may not be the information the sender provides. This misalignment is where the problem often occurs during hand-off communication," says Ana Pujols McKee, MD, executive vice president and chief medical officer, The Joint Commission. "Failures in hand-off communication can result in a sequence of misadventures and adverse events which can include medication errors, medical complications, readmissions, and even loss of life. We encourage health care organizations to use our new Sentinel Event Alert to help improve their own hand-off communication process."
Sentinel Event Alerts are available on The Joint Commission website at http:// www.jointcommission.org/sentinel_event.aspx..