Alert on Inadequate Hand-off Communication

This Alert on Inadequate Hand-off Communication is from The Joint Commission.


The Joint Commission Issues New Sentinel Event Alert on Inadequate Hand-off Communication

Communication Failures a Major Contributor to Adverse Events in Health Care

By: Katie Looze Bronk, Media Relations Specialist

Communication failures in U.S. hospitals and medical practices were at least partly responsible for 30 percent of all malpractice claims resulting in 1,744 deaths and $1.7 billion in malpractice costs over five years, according to a 2015 study.1  The Joint Commission has issued a new Sentinel Event Alert to provide hospitals and other health care settings with seven recommendations to improve communication failures that occur when patients are transitioned from one caregiver to another or from one team of caregivers to another.

The alert also reviews contributing factors to such “hand-off communication” failures, solutions, research, quality improvement efforts, and The Joint Commission’s related requirements.

“When a patient is handed off to another health care provider for continuing care, treatment or services, the type of information the receiving provider needs may not be the information the sender provides. This misalignment is where the problem often occurs during hand-off communication,” said Ana Pujols McKee, MD, executive vice president and chief medical officer, The Joint Commission. “Failures in hand-off communication can result in a sequence of misadventures and adverse events which can include medication errors, medical complications, readmissions and even loss of life. We encourage health care organizations to use our new Sentinel Event Alert to help improve their own hand-off communication process.”

The seven recommendations to improve hand-off communication include:

  1. Demonstrate leadership’s commitment to successful hand-offs and other aspects of a safety culture.
  2. Standardize critical content to be communicated by the sender during a hand-off—both verbally and in written form.
  3. Conduct face-to-face hand-off communication and sign-outs between senders and receivers in locations free from interruptions—include multidisciplinary team members, the patient and family, as appropriate.
  4. Standardize training on how to conduct a successful hand-off.
  5. Use electronic health record capabilities and other technologies to enhance hand-offs.
  6. Monitor the success of interventions to improve hand-off communication and use the lessons to drive improvement.
  7. Sustain and spread best practices in hand-offs and make high-quality hand-offs a cultural priority.



1CRICO Strategies. Malpractice risk in communication failures; 2015 Annual Benchmarking Report. Boston, Massachusetts:

The Risk Management Foundation of the Harvard Medical Institutions, Inc., 2015 (registration required for download).