The Joint Commission, an organization responsible for the accreditation of hospitals in the United States, has released Sentinel Event Alert No. 58 “Inadequate Hand-off Communication” in September 2017.  

Joint Commission Sentinel Event Alert 58: Handoff Communication

A Sentinel Event Alert is issued by the Joint Commission when they have identified specific types of sentinel event (those likely to cause death or serious injury) and adverse events and other high-risk conditions.  A Sentinel Event Alert describes the associated common underlying causes, and recommends steps to reduce risk and prevent future occurrences.  Sentinel Event Alerts are not issued on any specific schedule, but rather when the Joint Commission has identified the risk.

Included in this Sentinel Alert, the Joint Commission has recommended the standardization of tools and methods used for communication, and has further called out I-PASS as such a method.  We at the I-PASS Institute are encouraged to see the continuing and growing awareness of the problem, and I-PASS as a solution, and we are continuing our efforts to help hospitals implement I-PASS.