Laura K. Botwinick, Co-Director, Joint Commission International Center for Patient Safety;
Dennis S. O'Leary, MD, President, Joint Commission on Accreditation of Healthcare Organizations

      The Joint Commission's Sentinel Event Database provides evidence that the most significant root causes of sentinel events relate to failures in communication and handoffs. This session will discuss the development of National Patient Safety Goals (NPSGs) to address these key areas, strategies for improving communications and handoffs, and Joint Commission public policy initiatives related to these issues, including health literacy, health professions education, and emergency management. Activities of the Joint Commission International Center for Patient Safety will also be discussed.
      After this presentation you will be able to:

• Discuss the NPSGsrelated to communication and handoffs.
• Implement strategies for improving communication and handoffs.
• Describe how to addressing key public policy initiatives improvethese issues.