Joint Commission aims to improve patient hand-offs

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High miscommunication rates on patient hand-offs are the motivation behind the Joint Commission's latest collaboration with hospitals via its Center for Transforming Healthcare. In all, 10 hospitals from around the U.S. are tag-teaming with the hospital oversight group to learn about and ultimately prevent such "breakdowns," which account for 80 percent of serious medical errors, according to a statistic highlighted by the Joint Commission. 

"We know that breakdowns in communication that can occur when patients are handed-off from one caregiver to another are a leading cause of patient harm and medical errors," Ronald Peterson, president of the Johns Hopkins Hospital and Health System--one of the participating hospitals--said in a statement. "Few areas within the spectrum of patient care give us such an enormous opportunity to improve patient outcomes and reduce mistakes as improving these communications. The Joint Commission's initiative in this area is a welcome start." 

 At the initiative's outset in August 2009, the hospitals involved discovered that roughly 37 percent of hand-offs could be deemed "defective," meaning the new caregiver wasn't able to care for their patient safely. Since then, many of those hospitals were able to drastically reduce their defective hand-off numbers by embracing the Joint Commission's SHARE tactics. SHARE stands for:

  • Standardizing critical content: Make sure a patient's history and other key information is readily available and easy to comprehend.
  • Hardwiring within your system: Identify new and existing technologies to aid in a patient's hand-off.
  • Allowing opportunity to ask questions: Rather than take all information about a patient at face value, check and double check with others involved in the patient's care to ensure accuracy.
  • Reinforcing quality and measurement: Essentially, hold your colleagues (as well as yourself) accountable for actions taken and monitoring compliance.
  • Educating and coaching: Teach all colleagues the ins and outs of successful hand-offs. 

The other nine hospitals participating in the collaboration include Exempla Lutheran Medical Center in Wheat Ridge, Colo.; Fairview Health Services in Minneapolis; Intermountain Healthcare LDS Hospital in Salt Lake City; Kaiser Permanente Sunnyside Medical Center in Clackamas, Ore.; Mayo Clinic Saint Marys Hospital in Rochester, Minn.; New York-Presbyterian Hospital; North Shore-LIJ Health System's Steven and Alexandra Cohen Children's Medical Center in New Hyde Park, N.Y.; Partners HealthCare's Massachusetts General Hospital in Boston; and Stanford Hospital & Clinics in Palo Alto, Calif. 

To learn more about the collaboration:
- here's the Joint Commission press release
- read this Boston Globe: White Coat Notes piece
- check out this Wall Street Journal Health Blog post

Related Articles:
Joint Commission launches program to stop patient care breakdowns
Study: Harm from patient hand-offs is common
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