HomeTopicsPatient and Staff SafetyWhat doctors can do to prevent medical errors during transitions of care

What doctors can do to prevent medical errors during transitions of care

By Michael Wong and Stephen Routledge

Medical errors can be costly for both patient and hospital. As defined by The Joint Commission:

‘Transitions of care’ refer to the movement of patients between health care practitioners, settings, and home as their condition and care needs change. For example, a patient might receive care from a primary care physician or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she may receive care from a visiting nurse or support from a family member or friend.

A 2012 Joint Commission report focusing on transitions of care estimated that 80 percent of medical errors involve miscommunication between caregivers during handoff between medical providers. In a 2016 presentation Helen Haskell, President, Mothers Against Medical Error and Consumers Advancing Patient Safety showed that medication errors are the leading cause of medical harm and extended stays in hospital patients. Patients are estimated to be exposed to one medication error each day, and 1 in 4 hospital errors occur during prescription or administration. According to the World Health Organization, global costs associated with medication errors are US$ 42 billion annually.

In order to keep patients safe, clinicians should focus on 3 key points along the patient’s continuum of care:

  • Upon Admission to the Healthcare Facility
  • During Patient Recovery at the Healthcare Facility
  • Upon Discharge from the Healthcare Facility

1. Upon admission

Patient admission is a critical time for risk assessment. Clinicians should employ screening tools to identify high-risk patients before procedures. As examples of screening that should occur on admission, according to recommendations released by expert panels brought together by the Physician-Patient Alliance for Health & Safety, assessments should be done particularly for:

Moreover, because we are in the midst of an opioid epidemic, patients potentially receiving opioids can be assessed using the Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose (RIOSORD), an analytical model designed to define elevated risk of overdose or life-threatening respiratory depression.

It is crucial that the results of these tests be quickly communicated to all clinician teams responsible for the patient through their stay. This includes special attention to the patient’s current medication and any existing conditions.

2. Patient recovery

As patients recover from procedures, it is common for Patient Controlled Analgesia (PCA) pumps to be employed to manage pain. For the opioid naive, incorrect dosages can lead to opioid-related respiratory depression.

Research published in Anesthesia & Analgesia suggests that an electronic checklist may help, especially during intraoperative transfers of care. The PPAHS PCA Safety Checklist is a free downloadable resource developed by a panel of experts to reduce the risk of opioid-related adverse events.

Continuous electronic monitoring should also be employed for all patients receiving opioids. This includes the use of pulse oximetry and capnography monitors. Intermittent spot checks are not sufficient to detect the signs of opioid-related respiratory depression. A key study by Melissa Langhan (Melissa Langhan, MD (Assistant Professor of Pediatrics, Emergency Medicine, Yale School of Medicine), quantified this as an average of 3.7 minutes quicker than pulse oximetry monitoring.

3. Patient transfer and discharge

Patients’ non-adherence to physician-recommended medical treatment remains a persistent problem. It is estimated that 50 per cent of patients do not take their medications as prescribed. Consequently, clinicians should take steps to actively engage patients and their families as partners in their health. Most importantly, before transfer and discharge clinicians should ensure that patients have the information they need to use their medications safely.

Clinicians should make sure that their patients understand the answers to the following five questions about their medications:

  1. Have any medications been added, stopped, or changed, and why?
  2. What medications do I need to keep taking, and why?
  3. How do I take my medication, and for how long?
  4. How will I know if my medication is working, and what side effects do I watch for?
  5. Do I need any tests and when do I book my next visit?

We encourage clinicians to download a PDF version of these 5 questions and share with their patients here. The tool was jointly developed by several organizations aiming to improve communication between patients and their caregivers with prescribers. It is available in over 22 languages and can be customized with a logo for implementation in a healthcare facility.

For more resources dedicated to patient safety, please visit the CPSI and PPAHS websites.

Michael Wong, JD, is the Founder & Executive Director of the Physician-Patient Alliance for Health & Safety and Stephen Routledge, MPH, is Patient Safety Improvement Lead, Canadian Patient Safety Institute.


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