Joint Commission Center for Transforming Healthcare Tackles Miscommunication Among Caregivers

The Joint Commission Center for Transforming Healthcare has teamed up with a group of ten leading U.S. hospitals and health care systems to use new methods to find the causes of and put a stop to dangerous miscommunications between caregivers when responsibility for patients is transferred or handed-off.

Health care organizations have long struggled with the process of passing necessary and critical information about a patient from one caregiver to the next, or from one team of caregivers to another. A hand-off process involves “senders,” the caregivers transmitting patient information and releasing the care of the patient to the next clinician, and “receivers,” the caregivers who accept the patient information and care of the patient.

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.

For more information, read the full press release or visit the Joint Commission Center for Transforming Healthcare website at