Sentinel Event Alert 58: Inadequate Hand-off Communication¶
The Joint Commission. (2017). Sentinel Event Alert 58: Inadequate Hand-off Communication: Inadequate Hand-off Communication.
Cited by¶
2 citations across 2 artifacts.
Each citation links to the sentence it supports in the citing article.
Primes¶
- Custody Transfer
- In hospital care, structured handoff protocols are explicit acceptance rituals for patient responsibility, and missing handoffs are a leading cause of adverse events.
This sourceDefines a patient handoff as a transfer and acceptance of patient care and responsibility achieved through effective communication, establishes structured handoff protocols (standardized content, read-back/confirmation) as acceptance rituals, and identifies inadequate handoffs as a contributing factor to adverse events including medication errors, complications, and death.
- In hospital care, structured handoff protocols are explicit acceptance rituals for patient responsibility, and missing handoffs are a leading cause of adverse events.
Domain-specific¶
- Handoff Loss
- Patient handoffs are so reliably lossy that patient-safety bodies, including The Joint Commission, have long identified communication failures at transitions of care as a leading root cause of serious adverse events
This sourceThe Joint Commission's sentinel-event alert on inadequate hand-off communication as a recognised patient-safety problem.
Supported in partVerified against a saved copy of the source
“A common problem regarding hand-offs, or hand-overs, centers on communication”
- Patient handoffs are so reliably lossy that patient-safety bodies, including The Joint Commission, have long identified communication failures at transitions of care as a leading root cause of serious adverse events
Verification¶
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