Dear Colleagues,
This month, Patient Safety Link continues its series of theme issues regarding the
World Alliance for Patient Safety’s nine Patient Safety Solutions (read more here), which address what the
Alliance and the Joint Commission International Center for Patient Safety (ICPS) consider
some of today’s most important global health care safety challenges.
August’s Patient Safety Solution is “Communication During Patient Hand-Overs” (read the entire
solution here). As stated in the Solution, “Gaps in hand-over (or hand-off) communication
between patient care units, and between and among care teams, can cause serious breakdowns in
the continuity of care, inappropriate treatment, and potential harm for the patient.”
Knowing as much as possible about each patient at all times and making sure all of the
patient’s subsequent caregivers are completely informed are integral factors in maintaining
optimal patient safety.
In our first article, “A Model for Building a Standardized Hand-off Protocol,” one
organization’s interactive 90-minute hand-over workshop to develop a standardized process for
the hand-over is described, including descriptions of how the improved hand-over process
aided patient safety. “SBAR: A Shared Mental Model for Improving Communication Between
Clinicians,” details how the importance of sharing a common mental model in communication
hand-overs prompted efforts to spread the use of the SBAR (Situation,
Background, Assessment, and Recommendation) tool at
OSF Joseph Medical Center, in Bloomington, Illinois, USA. “Focus on Five: Strategies to
Improve Hand-Off Communication: Implementing a Process to Resolve Questions” continues in
the same vein, describes five strategies to make sure hand-over communication occurs
effectively and efficiently.
The Patient Safety Practices database on the Center's Web site contains many links to
helpful resources related to hand-overs and other communications issues. Click here to view those links.
In our monthly book excerpt, we present a portion of Chapter Two of Improving
Hand-Off Communication, in which several of the most common types of hand-overs are
described and tips for performing the hand-overs are provided.
Finally, we want patients and caregivers everywhere to know that The Joint Commission has
launched a national campaign to help Americans understand their rights when receiving medical
care. “Know Your Rights” is part of The Joint Commission’s Speak Up™ program (read more here) that urges
people to take an active role in their own health care. “Know Your Rights” provides tips to
help people become more involved in their treatment, thus improving the safety and quality of
care received.
Does your organization have recent positive experiences with Patient Hand-Overs
that you would like to share? Let us know about your success! Send an email by selecting this
link: http://www.jcipatientsafety.org/24725/.
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Peter B. Angood, M.D., FRCS(C), FACS, FCCM
Vice President & Chief Patient Safety Officer, The Joint Commission
Co-Director,
Joint Commission International Center for Patient Safety | Laura
Botwinick
Co-Director
Vice President, Joint Commission Resources
Joint
Commission International Center for Patient Safety |