Joint Commission: Medical errors in hospitals tied to 'handoffs' of patients

The Joint Commission, which accredits hospitals, released an update on a collaborative project with 10 health systems tragetting the frequent errors that happen in hospitals when a patient is handed off from one provider to another.

"The Joint Commission said that the ten hospitals and systems that volunteered to collaborate on the issue initially found that hand-offs were defective 37% of the time," The Wall Street Journal Health Blog reports. "That's important, because those crossed signals are estimated to be associated with 80% of serious medical errors, the commission said. Among the common reasons the participating hospitals cited for hand-off difficulties: an institutional culture that doesn't emphasize teamwork and respect, ineffective communication methods, inadequate time carved out for the transfer, inaccurate or incomplete information from the sender and an inability on the receiver's end to focus on the patient due to other priorities. Solutions were developed to address the common complaints — for example, establishing a 'quiet zone' that's dedicated to sharing patient information in a non-distracting setting. Organizations that fully implemented the solutions cut their defective hand-off rates by an average of 52%, according to the group" (Hobson, 10/21).

The Boston Globe's White Coat Notes: "Doctors at Mass. General said they are focusing on improving hand-offs in two key areas -- when community hospitals transfer patients to the medicine department, and when nursing homes send patients to the emergency room. ... The hospital now is making sure the new doctor has a phone number for the patient's sending physician. … Both the Joint Commission and Mass. General said they will have results of the project next year" (Kowalczyk, 10/21).

Modern Physician: "This is the second project for the Center for Transforming Healthcare, a quality-improvement and safety arm the Joint Commission established in 2009" (McKinney, 10/21).

Meanwhile, "[a] proposed rule outlining how long-term care facilities and hospice providers should cooperate on patients' services is expected to be issued Friday by the Centers on Medicare and Medicaid Services," CQ HealthBeat reports. "The regulation would require long-term care facilities, such as nursing homes, to have a written agreement with hospice organizations that spells out the roles and duties of each provider. The goal is to make sure that patients get appropriate care, with no duplicative treatments or unmet service needs" (Adams, 10/21).

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This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.