The relationship between transitions of care and medical errors is so clear, that leadership teams should be aware of what's required to protect patient safety.
What happens at a hospital when a patient is transferred among care teams, treatment facilities, or from hospital to home?
If the process doesn't go much beyond white boards or wheelchairs, it is time for an update.
That's essentially the advice of The Joint Commission, which has released a sentinel event alert on communications during transitions of care.
"While it sounds simple, a high-quality hand-off is complex," says the document. "Failed hand-offs are a longstanding, common problem in healthcare. Nevertheless, gaps in communication during hand-off processes continue to exist, thereby increasing patient safety risk."
The relationship between transitions of care and medical errors is so clear, that some of the key statistics in the document come from the research arm of a malpractice insurer.
The sentinel event alert is not a notice of a new standard hospitals will have to meet as part of the commission's accreditation process. Instead, it is designed to give providers and hospital administrators a heads-up on potential problem areas.
Ana McKee, MD, is the executive vice president and chief medical officer of The Joint Commission. The organization decided to issue the alert, in part, because the number of handoffs has increased dramatically, she says, and because communication during hand-offs can be a challenge for hospitals.
Tinker Ready is a contributing writer at HealthLeaders Media.