Page 49 - Hospitalists - Risks When You're the Doctor in the House (Part One)

SVMIC Hospitalists - Risks When You’re the Doctor in the House

Inadequate handoff communication is a contributing factor to

adverse events, including many types of sentinel events. The
Joint Commission’s sentinel event database includes reports of

inadequate handoff communication causing adverse events,
including wrong-site surgery, delay in treatment, falls, and

medication errors. A study released in 2016 estimated that
handoff communication failures in U.S. hospitals and medical

practices were responsible, at least in part, for 30 percent of
all malpractice claims, resulting in 1,744 deaths and $1.7 billion

in malpractice costs over five years. As part of its standard of
22
provision of care, treatment, and services, The Joint Commission

requires that the “process for handoff communication provides
for the opportunity for discussion between the giver and the

receiver of patient information”. Consideration should be given
23
to the implementation of a standardized approach for handoff

communication. Patient handoffs are a significant challenge
in healthcare due to the sheer number of handoffs (often in an

urgent or emergent situation), lack of a standardized protocol,
ineffective communication skills, distractions, interruptions,

timing, and lack of time or staff.

The primary barriers to effective communication are:

• Handoff failures between physicians assuming call;

• Situations in which important information is not known or

shared;

• Poorly-defined roles for hospitalists, admitting physicians,
and specialists;

22 Sentinel Event Alert, Issue 58, September 12, 2017.
23 The Joint Commission. Comprehensive accreditation manual. CAMH for hospitals: the official
handbook. Oakbrook Terrace (IL): Joint Commission; 2010

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