October 1, 2010 | American Society of Registered Nurses®
Journal of Nursing

Joint Commission Sets Goal for 400 Hand-Off Failures Per Day

SAN FRANCISCO, CA (ASRN.ORG) -- More than a year after The Joint Commission enlisted 10 hospitals to look closely at why patients’ medical information isn’t adequately shared between health care professionals, the project has come up with answers, and effective solutions.

As a group, the hospitals had a 37 percent defect rate in patient transfer communications and were able to cut that by half, said Mark Chassin, MD, president of The Joint Commission, the accrediting organization for U.S. hospitals. He announced the results of the study this week.

Each time a patient moves from one area of a hospital to another, or leaves the hospital to go to another care facility, that patient’s key medical information is essential for the highest quality of care. “Every patient hand-off provides many opportunities for error,” Chassin said. Studies estimate that as many as 80 percent of preventable errors begin with poor communication between caregivers.

“Time and time again, we’ve found problems with hand-offs at the heart of safety and quality problems at our institution,” said Kevin Tabb, Chief Medical Officer at Stanford Hospital. Working with the study group, he said, “has been particularly valuable to make sure we learn from each other’s successes and failures. There are a fair number of different types of hospitals represented here, yet everybody is facing similar issues.”

The reasons for failed hand-offs were many, Chassin said, but common themes did emerge regardless of the type of hospital: Lack of teamwork and respect between senders and receivers, and different expectations between senders and receivers about what information should be conveyed were two of the most frequently found.

Sometimes, Chassin said, the failures were caused by distractions, competing priorities or lack of a standardized method for the communication.

 

QUICK FACTS:

The most commonly shared causes for hand-off defects at the participating hospitals were:

- Sender provides inaccurate or incomplete information

- Culture’s lack of teamwork and respect does not promote successful hand-off

- Sender and receiver have different expectations

- Sender has little knowledge of patient

- Ineffective communication method

- Unsynchronized timing between hand-off and physical transfer of patient

 

The hospitals in the study group were:

-Stanford Hospital, Stanford, CA

- Fairview Health Services, Minneapolis, Minnesota

- Intermountain Healthcare LDS Hospital, Salt Lake City, Utah

- The Johns Hopkins Hospital, Baltimore, Maryland

- Kaiser Permanente Sunnyside Medical Center, Clackamas, Oregon

- Exempla Lutheran Medical Center, Wheat Ridge, Colorado

- Mayo Clinic Saint Mary’s Hospital, Rochester, Minnesota

- New York-Presbyterian Hospital, New York

- North Shore-LIJ Health System Steven and Alexandra Cohen Children’s Medical Center, New Hyde Park, New York

- Partners HealthCare, Massachusetts General Hospital, Boston

 

Residents live “in lunar cycles,” Gibbons said. “One month you’re the sender, the next you’re the receiver.”

Although The Joint Commission had already created a set of standards for hand-off communication, it felt the problem was still so serious that a second effort was justified. “We as a commission have focused on hand-offs as a known problem,” Chassin said, “and each of the participating hospitals was already devoting significant resources to try to avoid failures. That’s why we are working to come up with better and new ways to systematically handle them.”

The solutions include: standardizing critical content, including details of a patient’s medical history; identifying new and existing technologies to assist in the hand-off; and allowing the opportunity for sender and receiver to ask questions.

“Our consumers assume that when they move from one place to another that doctors get together and discuss them. The reality is I’m not sure we’re achieving the standards patients expect of us. Our job is to make our practices achieve that.”

Chassin said The Joint Commission would like to see hospitals achieve a 90 percent success rate. But based on an estimated 4,000 hand-offs a day in a teaching hospital, even that success rate would still mean 400 failures a day. “The consequences of these kinds of miscommunications cause serious problems,”


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