In an effort to reduce medical errors during transfers of care, Stephen Routledge, MPH, (Patient Safety Improvement lead, Canadian Patient Safety Institute) and Michael Wong, JD, (founder and executive director, Physician-Patient Alliance for Health & Safety) recently co-authored an article, “What doctors can do to prevent medical errors during transfer of care.”
The Joint Commission has emphasized the need for collaboration across the entire care continuum to prevent adverse events and patient deaths:
Unfortunately, these transitions do not always go smoothly. Ineffective care transition processes lead to adverse events and higher hospital readmission rates and costs. One study estimated that 80 percent of serious medical errors involve miscommunication during the hand-off between medical providers. Problematic transitions occur from and to virtually every type of health care setting, but especially when patients leave the hospital to receive care in another setting or at home, according to experts on this issue. To reduce both readmission rates and adverse events, hospitals must improve the effectiveness of transitions of care in which they play a role.
In order to keep patients safe, clinicians should focus on three key points along the patient’s continuum of care:
- Upon admission
- During patient recovery
- Upon patient discharge
Wong emphasized the need to ensure patient safety during recovery, saying, “We have heard of many instances of deaths following successful procedures.” He cited the cases of Logan Parker, who had undergone surgery for obstructive sleep apnea (OSA) with elements of central sleep apnea, and Tyler Ireland, who died of opioid-induced respiratory depression while on a patient-controlled analgesia (PCA) pump.
As well, Wong encouraged clinicians to share these five questions with their patients
- Have any medications been added, stopped, or changed, and why?
- What medications do I need to keep taking, and why?
- How do I take my medication, and for how long?
- How will I know if my medication is working, and what side effects do I watch for?
- Do I need any tests and when do I book my next visit?
These 5 questions were developed by ISMP Canada, the Canadian Patient Safety Institute, Patients for Patient Safety Canada, the Canadian Pharmacists Association and the Canadian Society for Hospital Pharmacists to help patients and caregivers start a conversation about medications to improve communications with their health care provider.
Clinicians are encouraged to download a PDF version of these 5 questions here.