![]() ![]() “Potential for patient harm-from the minor to the severe-is introduced when the receiver gets information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed,” The Joint Commission wrote. On September 12, The Joint Commission published Sentinel Event Alert 58 on inadequate handoff communications and their effect on patient care. This exchange is a huge weak point in healthcare each handoff runs the risk of having key treatment information being garbled, forgotten, or not passed on. These transfers can be as dramatic as airlifting a patient to a specialty hospital and telling the EMTs that the patient thinks she can fly and will try to jump out of the helicopter, or as mundane as a nurse ending her shift and telling her replacement the patient has been taken off a certain medicine. Read the full sentinel event data summary.This article appears in the November 2017 issue of Patient Safety Monitor Journal.Ī patient handoff (also known as transitioning) is both the act of passing a patient between caregivers and the information exchanged between the sender (the provider giving away the patient) and the receiver (the provider taking the patient). Reporting of sentinel events to The Joint Commission is a voluntary process, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. The remaining sentinel events were reported either by patients or their families, or employees of a healthcare organization. Most sentinel events (90%) were voluntarily self-reported to The Joint Commission by an accredited or certified healthcare organization. Our goal is to help prevent these types of adverse events from occurring again.” “For each sentinel event, a Joint Commission patient safety specialist worked with the impacted healthcare organization to identify underlying causes and improvement strategies. “COVID-19 continued to present challenges to healthcare organizations throughout 2022, and we saw the number of sentinel events increase above pre-pandemic levels,” said Haytham Kaafarani, MD, MPH, FACS, Chief Patient Safety Officer and Medical Director, The Joint Commission. ![]() Of all the sentinel events, 20% were associated with patient death, 44% with severe temporary harm and 13% with unexpected additional care/extended stay. ![]() Most reported sentinel events occurred in a hospital (88%).
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