Few nurses would be OK with settling for substandard care of patients under their charge. Yet when it comes to patient handoffs to another caregiver, clinicians too often do just that: They commonly transfer the responsibility of care with incomplete and hastily thrown together information that fails to protect the patient.
“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 handoff communication,” said Ana Pujols McKee, MD, executive vice president and chief medical officer of The Joint Commission.
“Failures in handoff communication can result in a sequence of misadventures and adverse events, which can include medication errors, medical complications, readmissions, and even loss of life.”
In fact, The Joint Commission (TJC) reports that communication failures played a role in nearly a third of all malpractice claims over a 5-year period, resulting in a tragic 1,744 deaths and $1.7 billion in costs.
“Facts, figures, or findings got lost between the individuals who had that information and those who needed it — across the spectrum of health care services and settings,” CRICO reported.
The Joint Commission recently issued a Sentinel Event Alert to call attention to the dangerous problem of inadequate handoff communication.
“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 alert explains. “When handoff communication fails, many factors are involved, such as health care provider training and expectations, language barriers, cultural or ethnic considerations, and inadequate, incomplete, or nonexistent documentation, to name just a few.”
The Joint Commission recommended 8 tips for improving patient handoffs (if you prefer visual aids, an infographic is available here):
Now, a note to nursing leaders: The Joint Commission also advises the necessity of demonstrating leadership’s commitment to successful handoffs and other aspects of a safety culture. That includes providing the support, time, and funding for handoff quality improvement initiatives. The Joint commission also encourages monitoring the success of handoff interventions to improve communication and to use the lessons gained to drive continued improvement.
Finally, sustain as well as spread best practices in patient handoffs to contribute to improved patient care beyond your organization. Making high-quality handoffs a cultural priority and expectation is a huge step forward in preventing avoidable patient harm.