Joint Commission recommends all hand-off procedures to have both written and verbal components for the critical hand-off information.
“2. Standardize critical content to be communicated by the sender during a handoff – both verbally (preferably face to face) and in written form. Make sure to cover everything needed to safely care for the patient in a timely fashion.
Standardize tools and methods (forms, templates, checklists, protocols, mnemonics, etc.) to communicate to receivers.”
Real Life Example
67 Lincoln Street vs 67 Lincoln Park
A 911 call was placed multiple times and the address was verbally stated and misinterpreted as street vs park. First responders showed up to the wrong address, no one was there, and they left as per standard EMS protocol. On the fifth try they realized they were going to the wrong address.
If a doctor or clinic calls 911 or the police administrative number, the doctor’s address shows up on the dispatch screens, not the patient’s address. If the doctor fails to explain that the address in the system is not the correct address, or the 911
dispatcher fails to further inform first responders that the forwarded address is not the correct address, first responders will go to the wrong address, not find any one, and leave. If the doctor does not follow up, no one will ever show up.
Sentinel Event Alert 58: Inadequate hand-off communication
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This information does not constitute legal advice and should not be relied upon as a substitute for