Joint Commission Touts Research on Reducing Handoff Failures

Cheryl Clark, October 22, 2010

A 10-hospital collaborative to reduce handoff failures, the root cause of four in five adverse events, successfully cut by 52% the number of faulty handoffs by identifying reasons why communication fails, says Mark Chassin, president of the Joint Commission.

Chassin says that when these solutions are refined, they may become part of the commission's hospital accreditation process, with a report on their outcomes expected by mid 2011. Also in the works is the development of a way to quantify how reducing handoff failures improves outcomes, he says.

Chassin spoke during a briefing with representatives of several hospitals participating in the commission's Center for Transforming Healthcare. And during that session, many noted that lack of respect between sender and receiver, and varying cultures and focus—for example between the emergency room team and an inpatient team—may explain some reasons why information that must be conveyed is not.

"This is a ubiquitous problem," said Chassin, former Executive vice president for Excellence in Patient Care at Mount Sinai School of Medicine and former Commissioner of the New York State Department of Health.

"There's potential for miscommunication "each time a patient moves from one area of care to another, for example, from the emergency department to a medical surgical inpatient unit, from an intensive care unit to an inpatient unit or from a recovery room to an inpatient unit or from one set of providers to another set during a change of shift."

In just one average-sized teaching hospital, for example, he says there are 4,000 patient handoff opportunities for error every day, " or 1.6 million a year. If you think about those staggering numbers, you think about how many opportunities there are for miscommunication."

The hospitals, which began the project in August, 2009, realized that on average, 37% of their handoffs were defective.  Information that was provided by the sender, or received by the receiving caregiver, was insufficient to guarantee safe care, they realized.  Additionally, 21% of the time senders were dissatisfied with the quality of the handoff.

"It is unfortunately not uncommonly the case that the caregivers involved in sending a patient to the care of another set of caregivers don't really believe the time that is necessary to do this process well is something they ought to be spending their time on," Chassin says.

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