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Medical Errors are the Third Leading Cause of Death in the U.S.

We’ve all heard the horrific stories about patients undergoing amputation surgery only to have the surgeon amputate the wrong body part.  We hope and pray these are isolated incidents, right?  Well a new study published last week in the BMJ shows that medical errors in hospitals and other healthcare facilities are more common than we think and are the third leading cause of death in the United States.

While a myriad of factors may contribute to a medical error, one of the leading causes is poor transitions of care – when patients are transitioned from one department, facility or caregiver to another.

For post-acute care providers, poor transitions of care may lead to hospital readmissions, which can have negative implications for our seniors and our bottom line. Ensuring the coordination and continuity of health care as individuals transfer between different locations or different levels of care is a team effort involving caregivers, therapists, physicians, pharmacists, nurses, families and the individual.

Where do care transitions go wrong?

Poor communication, complex discharge instructions, changes in medication and misconceptions about the sharing of medical information can contribute to errors during a care transition.

So, how do we improve our transitions and ensure the safety of the individuals in our care?

Here are 5 way to improve transitions of care at your organization:

  1. Organization commitment: have a commitment to overcome barriers and standardize and improve transitions. Develop policies and procedures that guide the various transitions such as skilled nursing to home health or home health to the assisted living community.
  1. Accountability: every transition task must be assigned to a designated person with their specific responsibilities made clear. One person should be assigned overall responsibility for the entire transition of care.
  1. Effective communication: between team members at the current care setting and team members at the new care setting. One technique for communicating critical information that requires immediate attention and action concerning a resident’s condition is SBAR. What is SBAR?
    • Situation – what is happening at the present time with the person?
    • Background – what is the clinical background or context?
    • Assessment – what do I think the problem is?
    • Recommendation – what would I recommend to correct the problem?

The Agency for Healthcare Research and Quality provides education to help improve transitions of care, including videos to demonstrate effective use of the SBAR technique.

  1. Education: is essential in getting the individual and family involved in the transition.
  2. Medication reconciliation: performing medication reconciliation avoids medication errors such as omissions, duplications, dosing errors and/or drug interactions. This should be done with any transition of care.

A successful transition of care includes the following 6 steps by caregivers:

  1. Recognize a status change in the individual
  2. The interdisciplinary team determines the most appropriate care transition
  3. The sending care setting communicates with the receiving care setting prior to the individual arriving
  4. The individual is physically handed over to the receiving care setting
  5. Both the sending and receiving care settings verify that the individual has been handed over and essential information has been received
  6. The sending care setting confirms successful transition with the new care setting within 24 hours

Implementing an effective care transition process is an important step in reducing medical errors, hospital readmissions and costs. A successful transition process ensures clear communication to all parties, proper education to the individual and their family, and clear assignment of accountability for all involved.

Let us know how you’ve improved your care transitions.


If you would like to learn more about improving transitions of care, our webinar titled Implementing Proper Transitions of Care to Prevent Rehospitalization.

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