Patient handoffs happen so frequently that even small errors can have a major impact on the quality of care a hospital delivers. By the same token, a little more attention to detail around handoff planning and execution can pay huge dividends.
Communication breakdowns that occur during patient handoffs raise the risk of medical errors and have long been a target for safety-oriented organizations. In a recent sentinel event alert (PDF), the Joint Commission noted that failed handoffs were among the causes of almost a third of malpractice claims over a five-year period. That translates to 1,744 deaths and $1.7 billion in malpractice costs.
Calls for increased transparency around hospital quality data have put a premium on improvements to basic, fundamental activities, as has pressure from organizations such as the World Health Organization and American College of Healthcare Executives to establish workflows aimed at curbing medical and medication errors. Nevertheless, the majority of teaching hospitals fail to standardize their handoff process, according to the Joint Commission alert.
The accrediting agency included a detailed set of best practices for developing and implementing an improved handoff system. Some highlights:
- Make handoffs focused and comprehensive. The Joint Commission recommends that in their plans hospitals identify all of the critical information that must be passed along during the hand-off process. That information forms the basis of training, workflow tools and the expectations of clinical staff.
- Establish standards and build a repeatable process around them. Once hospitals establish the scope of information needed for the handoff, they should develop tools and processes to standardize the process. The Joint Commission recommends tools such as checklists, forms, templates, and even mnemonics to improve compliance.
- Emphasize face-to-face interactions. The alert recommends establishing a consistent place and time for providers to meet in person, along with the patient and family, to exchange information in an environment without distractions and to encourage comprehensive communication.
- Use technology wisely. While EHRs, online portals and text messaging can be useful tools for standardizing handoff practices, the Joint Commission warns against leaning too heavily on them as a sole means of conveying information.