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Joint Commission Center for Transforming Healthcare Tackles Miscommunication Among Caregivers

October 22, 2010
by root
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An estimated 80 percent of serious medical errors involve miscommunication between caregivers when responsibility for patients is transferred or handed-off. Recognizing this as a critical patient safety issue, a group of 10 leading U.S. hospitals and health care systems teamed up with the Joint Commission Center for Transforming Healthcare (Oakbrook Terrac, Ill.) to use new methods to find the causes of and put a stop to these dangerous and potentially deadly breakdowns in patient care.

The Hand-off Communications Project began in August 2009. During the measure phase of the project, the participating hospitals found that, on average, more than 37 percent of the time hand-offs were defective and didn't allow the receiver to safely care for the patient. Additionally, 21 percent of the time senders were dissatisfied with the quality of the hand-off. Using solutions targeted to the specific causes of an inadequate hand-off, participating organizations that fully implemented the solutions achieved an average 52 percent reduction in defective hand-offs.

The 10 hospitals and health systems that volunteered to address hand-off communications as a critical patient safety problem are:

  • Exempla Lutheran Medical Center, Wheat Ridge, Colorado
  • Fairview Health Services, Minneapolis, Minnesota
  • Intermountain Healthcare LDS Hospital, Salt Lake City, Utah
  • The Johns Hopkins Hospital, Baltimore, Maryland
  • Kaiser Permanente Sunnyside Medical Center, Clackamas, Oregon
  • Mayo Clinic Saint Marys Hospital, Rochester, Minnesota
  • New York-Presbyterian Hospital, New York
  • North Shore-LIJ Health System Steven and Alexandra Cohen Children's Medical Center, New Hyde Park, New York
  • Partners HealthCare, Massachusetts General Hospital, Boston
  • Stanford Hospital & Clinics, Palo Alto, California



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