For anyone navigating the complex world of healthcare, understanding the intricate dance known as ‘transitions of care’ is essential. Transition in care is when your loved one moves from one type of care to another. For example: Your loved one is admitted to the hospital and now coming home. This is one transition. Going to the doctor’s office for an illness and then home is another type of transition. A two-transition example may be an aging loved one going from the hospital to a nursing home and then back home. Each transition carries its own dangers for errors and mistakes.
Patient Safety Week, which serves to highlight and reinforce our commitment to enhancing safety in healthcare delivery, is a pertinent time to focus on this critical aspect. In this comprehensive blog post, we’ll uncover the multifaceted nature of care transitions and the risks they pose. We’ll explore how these transitions impact you and your family, and importantly, how we can collectively tackle these challenges for safer, more reliable healthcare experiences.
A Closer Look: What Constitutes a ‘Transition’ in Healthcare?
The ‘In-Between’ Moments
When a patient moves from one healthcare provider or setting to another, such as from hospital to home or from primary care to specialty care, this is a ‘transition of care.’ While these moments may seem brief, they lay the foundation for the next phase of the patient’s health journey, making them incredibly significant.
Transitions can be traditional shifts like hospital discharges, but they also include changes between different stages or types of health care, such as upon diagnosis, at the onset of home care, or with terminal care planning. These periods demand extra caution as they mark the beginning or end of a phase of care, and ensure effective patient safety.
Why They Matter
Transitions of care mark points in the continuum of care when there is potential for miscommunication, misinterpretation of information, or unintended discrepancies in care. These lapses can lead to fragmented care, preventable adverse events, emergency department visits, and hospital readmissions, placing patients at heightened risks. It’s the role of healthcare professionals and caregiver networks to minimize these risks. A family member can also be aware of these concerns and advocate for their loved one. In this blog post we will help you understand what can be at risk.
The Crucial Role of Transitions in Care
Transitions in care are more than just logistical arrangements; they represent critical junctures in a patient’s health continuum. A proper transition should be seamless, encompassing the transfer of a patient from one level of care to another, ensuring their safety and well-being, without loss of information. It’s the handoffs that count, not the volumes. But between the harried discharges, schedule juggling, and information handoffs, are we protecting our patients well enough?
Risks Associated with Transitions
Understanding the potential pitfalls in transitions of care is the first step in safeguarding patients. Here, we’ll detail the common risks and their impact on the patient’s health trajectory.
Medication Errors: A Common, Costly Mistake
Medication errors top the charts as one of the most common issues during transitions. Whether it’s a prescription mix-up, a timing misjudgment, or improperly explained medications to patients, the consequences can be dire. According to AHRQ, medication discrepancies affect over 30% of patients during transitions and, astonishingly, contribute to an estimated 1.5 million preventable adverse drug events each year.
Medication reconciliation errors are alarmingly common, and nothing is as unsettling as a medication error transitioning from paper to practice. The wrong dose, an omitted medication, or a misunderstood administration time, these all-too-common errors can have severe consequences for patient safety.
Tales from the Bedside: Real World Stories:
One example of a type of medication error that can occur is told in this story. Mr. Smith was going home from the hospital. He is a bit forgetful and his wife manages his care. She was coming to pick him up. She asked if someone could bring him down to the main entrance in a wheelchair and she would pick him up there. It would be much easier for her if she didn’t have to park the car and come up to the unit to get him.
This seemed like a reasonable request however, Mrs. Smith did not hear his discharge instructions prior to him leaving. The instructions were given to Mr. Smith. We determined this gentleman was a high risk for being readmitted to the hospital in less than 30 days so we scheduled a follow up phone call. He went home on a Friday so the call wasn’t made until Monday.
We spoke to Mrs. Smith and found out when she went to her local pharmacy, she did not pick up his new medication because the co-pay was too much, and she couldn’t pay it, so he never started on his new medication to prevent blood clots.
Several red flags here. It is very important to ask about any new medications, the cost, what it is for, etc before leaving the hospital. Always have another person present during the discharge instructions for your loved one so that someone other than just the patient (who wants very badly just to go home) hears the instructions and is available to ask questions.
There are actions the hospital can take to help prevent this but these situations can occur and what if it was your loved one. We all need to be diligent in asking questions and understanding the treatment plan before making that transition to the next level of care. We need to advocate for our loved ones. There are professional health advocates available to assist and read between the lines for your loved one. We have included a listing of advocates from our directory here.
Communication Breakdowns
Imagine a patient discharged with unclear instructions about their post-discharge care. The downstream effects can be frustrating at best and life-threatening at worst. Communication breakdowns, ranging from language barriers to incomplete handoffs, can profoundly affect care continuity and patient understanding.
Tales from the Bedside: Real World Stories:
This is more of “common” occurrence than we would like to see but it happens. Usually when a patient is sent to a nursing home or assisted living there is paperwork sent along with them. Specifically a discharge summary. This is signed by the doctor and can be used as orders for the facility or community. If the discharge summary does not include all the orders for ongoing care this is the first time something can get missed. If the patient discharge instructions and the discharge summary do not match there are errors on one or the other and lead to confusion. The receiving level of care cannot use the patient discharge instructions as orders because the doctor does not sign it.
The Dangers of Discontinuity in Care
Lack of continuity in care is more than just an inconvenience—it’s a significant risk factor for patient safety. Without a through-line connecting various healthcare encounters, the potential for overlooking crucial aspects of care increases, leaving gaps that can compromise a patient’s well-being.
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The Impact on Families
Patients in the Crosshairs
For patients, these transition periods can be fraught with uncertainty. The loss of familiar surroundings and faces, combined with changes in their routines, can be disorienting and anxiety-inducing, potentially leading to poorer outcomes.
The Strain on Caregivers
Caregivers, too, feel the weight of transitions. Often serving as the bridge between multiple healthcare entities, the responsibility for ensuring a seamless transition can be overwhelming. The stakes are even higher when cognitive conditions like Alzheimer’s or dementia are part of the equation.
The Hardships for Healthcare Providers
Healthcare providers, while equipped to deliver care, face their own set of risks and challenges during transitions. From time constraints to interrupted care paths, the provider’s dilemma is balancing efficiency with thoroughness, often in a high-stakes, high-pressure environment.
Strategies for Safer Transitions
Establishing a Gold Standard
One of the most potent weapons against transition risks is the implementation of standardized protocols. These protocols, established to mitigate risk and enhance safety, serve as the backbone of effective transitional care practices.
Strengthening the Channel of Communication
Transparent and robust communication channels are of paramount importance. Ensuring information flows without hindrance, that all stakeholders are well-informed, and that communication standardization from patient records to verbal handoffs is the norm, not the exception.
Patient Education Empowerment
Educating patients and their families on their care plans and the necessity of actively championing their healthcare continuity is vital. Through education and empowerment, patients can partner with their providers to achieve safe transitions. Always have a care partner present during any transition to have another set of eyes and ears to ask questions and raise any concerns.
Conclusion
As we reflect on Patient Safety Week and the profound subject of transitions of care, it becomes clear that this is not just a professional obligation but a collective responsibility. From providers to caregivers, patients to policymakers, each of us has a role in ensuring that every transition is as safe and seamless as possible. While challenges will undoubtedly persist, our commitment to continuous improvement in this area will lead to safer, more navigable healthcare experiences for all. Patient Safety Week serves as a beacon, illuminating the path forward—a path that, when walked collectively, ensures better health outcomes and a more secure future for all.
Thanks for stopping by in honor of Patient Safety Week. We hope you gained a bit of wisdom along the way. We will see you back here soon on the blog!
Take Care,
Pam
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