Skip to Main Content

Instructors can request access to the Faculty Answers and Rationales. Email Customer Success ( for more information.


A well-known barrier in transitions of care is clear, consistent communication. This applies to both communication among the healthcare team and communication with patients. The Joint Commission estimates approximately 80% of serious medical errors are caused by poor communication between healthcare providers.1 Ineffective communication has been shown to lead to fragmented care and patient dissatisfaction.2

Several resources are available to improve communication between healthcare providers. The Joint Commission’s Targeted Solutions Tool (TST) for Hand-Off Communications can be used to identify barriers to exceptional performance and provide specific solutions to address each barrier. The Joint Commission recommends using the mnemonic SHARE to address causes of unsuccessful hand-offs: Standardizing critical content, Hardwiring within your system by using standardized forms, tools, and methods, Allow opportunity for others to ask questions and clarify information obtained, Reinforce quality and measurement through accountability and monitoring, and Educate and coach staff using standardized training on how to conduct successful hand-offs.3 Another standardized communication method is the SBAR (situation, background, assessment, and recommendation) technique. Although the SBAR technique was originally created by the U.S. Navy for communication on nuclear submarines, it has been highly utilized by the healthcare system as a template to provide clear communication. Using this method, healthcare providers are encouraged to first describe the situation and then provide succinct yet thorough background that may be needed. In the final steps, an assessment and clear recommendation should be communicated to the next provider.4

The use of standardized forms during transfers between various levels of care has demonstrated improved communication of patients’ advanced directives, improved safety perceptions, and increased patient satisfaction and outcomes.5-7 The development of a standardized hand-off tool with a coordinated medication reconciliation increases patient satisfaction regarding medication knowledge and meeting health-related goals, especially when patients are able to speak to a pharmacist about their medications.8

In addition to providing clear communication to the healthcare team, it is important to ensure that information is appropriately communicated to the patient. Proper training on health literacy should be implemented to teach the healthcare team how to measure health literacy and to provide strategies to break down difficult concepts. Resources available to help assess health literacy and train staff include the Agency for Healthcare Research and Quality (AHRQ) Pharmacy Health Literacy Center, Health Literacy Tool Shed, and the AHRQ Health Literacy Universal Precautions Toolkit. Patients at high risk for low health literacy should be screened. One popular tool that can be used to assess health literacy is the Newest Vital Sign (NVS). According to the 2003 National Assessment of Adult Literacy, individuals at high risk for poor health literacy are patients who are male, Hispanic, Black, American Indian/Alaska native, English language learners, older than 65 years of ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.