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Inadequate hand-off communication

Resource Type: Articles

This Joint Commissions Sentinal Event Alert (free download) focuses on ineffective communication in the patient handoff process, whether within or between health care organizations. A longstanding issue that health care professionals and administrators have sought to address, suboptimal handoffs due to inadequate or improper communication threaten safety and can lead to compromised patient outcomes. The article identifies a variety of factors found to contribute to these failed handoffs, including organizational culture, time issues and distractions. The authors discuss standardized measures employed to address handoff issues, including I-PASS and the Joint Commission’s TST, and offer several pneumonics such as ISBAR (i.e., Identification, Situation, Background, Assessment and Recommendation) to support successful care transitions. The Joint Commission also outlines seven recommendations for systematically addressing handoff communication issues both within hospitals and between organizations. These include adopting an organizational and administrative mindset that successful handoffs are of critical importance; adopting standardized approaches for both the transmission and receipt of information (as well as what information will be communicated); and investing in the success of the process by training and rewarding staff for successful handoffs. Also available is an “8 Tips for Successful Handoffs” infographic that presents the information in a colorful, concise image.

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Sentinel Event Alert 58: Inadequate hand-off communication. The Joint Commission website. Published September 11, 2017. Accessed March 11, 2020.

care coordination


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