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Inpatient Transitions of Care: Challenges and Safety Practices

Anna Satake PhD, MSN, GCNS, RN and Vanessa McElroy, MSN, PHN, ACM-RN, IQCI | March 27, 2024
View more articles from the same authors.


Transitions of care occur frequently during hospitalizations and present notable risks associated with communication, medication management, and caregiver preparedness. Inpatient transitions of care encompass the procedures and actions associated with moving a patient between different healthcare levels, settings, or between team members or shifts handoffs within a hospital. Seamless transitions are vital to maintain continuity and quality of care for the patient and family. This Primer will explore the typical patient safety risks linked with inpatient transitions and strategies to minimize and mitigate these risks. Other types of transitions, such as transitions across shifts, between healthcare facilities or from hospital to home, are discussed in other PSNet Primers (Handoffs and Signouts, Discharge Planning and Transitions of Care).

Challenges and Threats to Patient Safety

Consider a scenario where a patient – Mr. H, an 80-year-old man – arrives at the emergency department (ED) following a car crash and is unable to relate his medical history. Amidst the chaos of the ED, crucial medical information is lost. Due to the absence of a family member or caregiver, the healthcare team is unaware that Mr. H uses bilateral hearing aids and has a history of reacting to diphenhydramine (an antihistamine), resulting in delirium and hallucinations. Mr. H is transferred to the operating room for repair of multiple fractures. Subsequently, Mr. H is transferred to a critical care unit and his home medications, such as gabapentin for neuropathy and fluoxetine for depression, are missing from the postoperative medication orders. At night Mr. H is restless, which prompts diphenhydramine to be ordered for sleep. The next morning, the patient exhibits confusion. Mr. H is transferred again the medical/surgical unit. Mr. H’s family arrives and inquiries about his missing hearing aids and discusses the medications with the physician for the first time, expressing concern about his adverse reaction to diphenhydramine and the absence of home medications. The physician promptly adjusts the medication.

At every transfer across care setting and treatment team, the potential for miscommunication introduces opportunities for adverse outcomes. Effective communication between care teams is vital to ensure favorable health outcomes such as increased patient satisfaction, compliance, and overall health status.1

Communication Breakdowns

Healthcare Teams

The involvement of numerous teams in the communication process, where too many links in the chain can be broken, is why poor communication has been identified as a significant contributor to patient safety events, such as medical errors.2 Furthermore, the lack of standardized communication protocols and the delay in sharing patient information contributes to variations in information exchange practices, increasing the likelihood of errors and omissions.

Within healthcare facilities, patients receive care from diverse health care teams throughout their treatment. It is crucial to establish effective communication and handoffs between these teams to guarantee the accurate transmission of relevant medical information and patient preferences. Handoffs (which are discussed in more detail in another PSNet primer) serve as a means of transferring information between clinicians during shift changes, or when a patient moves between departments or when transitioning between different care teams or when transitioning to another facility.

Utilizing electronic health records has played an essential role in improving communication during handoffs. However, when insufficient transfer of patient information occurs during these transitions, it can lead to the miscommunication of vital patient details. Subpar communication may contribute to various negative outcomes, including diminished adherence to treatment, patient dissatisfaction, and inefficient utilization of resources.1

Patients, Families or Caregivers

Acute illness, changes in medical conditions, hospitalization, and adverse events impose a significant burden on the patient, their families, and caregivers. There is very little research about the correlation of patient-family engagement and patient safety, leading to practitioners lacking a strategy in utilizing effective interventions. Undue stress during hospitalization can also affect one's capacity to communicate, receive, and retain information and education, which plays a pivotal role in safe transitions and care planning. Additionally, health literacy, language barriers, and cultural differences can contribute to confusion, potentially resulting in insufficient involvement of patients and their families in comprehending shared medical information and a lack of participation in the decision-making process.

Medication Errors

An estimated 60% of medication errors occur during transitions of care and lead to avoidable hospitalization and prolonged hospital stays. Changes in care settings and exchanging and sharing information among multiple care team members may introduce errors in prescription orders, dosage adjustments, or medication administration protocols – all of which can jeopardize patient safety. Inadequate communication about medication changes can leave patients and caregivers uninformed, leading to non-compliance and increased risks.

Strategies to Improve Patient Safety

To address these risks, it is vital to create safety nets within systems to ensure seamless transitions with minimal associated risks. The primary objective of an efficient inpatient transition of care is to foster a seamless and patient-centered experience as well as to optimize accurate information exchange, thereby decreasing the risk of medical errors and elevating the overall quality of care and bettering patient outcomes.

Effective Communication among Healthcare Teams

The handover of patient care will consistently involve a complex exchange of patient information and an effective communication process. Effective communication between healthcare providers and patients is vital for patient safety and quality of care received.2 Improving communication between providers, defining roles clearly, and establishing robust resources yield positive results. Therefore, establishing communication standards between staff and providers at various points of care during a patient’s transition between locations or when care is handed off between shifts can enhance safety.

Despite considerable efforts in improving the handoff process, the exchange of information among providers continues to be suboptimal. To enhance team communication, there are several recommended best practices and evidenced-based tools that can assist in communications between team members, such as TeamSTEPPS. Providers and staff alike should also consider the concept of bullet rounds, a concise version of discharge rounds.3 A recent study indicates that brief rounds conducted in a multidisciplinary setting can improve communication among team members, reduce a patient's length of stay, and ensure continuity of care.4

Patient and Family Engagement

Active engagement and understanding of medical information and care goals by both the patient and their family are crucial for healthcare participation, compliance with care plans, and positive health outcomes. This involves ensuring that patients and families are provided ample time and space to actively participate, allowing their voices, concerns, and clarifications to be heard and addressed promptly. One example of a tool to support patient and family engagement is the Patient and Family Centered I-PASS tool, which provides a formal structure of family-centered rounds.

Another integral aspect of healthcare’s dedication to achieving quality outcomes involves a focus on health literacy and recognizing cultural diversity. Health literacy levels evolve with experience in navigating various health circumstances and making life-related health choices. The SHARE approach, developed by the Agency for Healthcare Research and Quality (AHRQ), provides a model to engage patients and families across all decisions in care, including transitions in care, and offers communication tips regarding health literacy and culture. It is essential for every member of the healthcare team to consistently assess and reassess health literacy levels, particularly during educational and information-sharing processes.

Medication Safety

Medication reconciliation has been part of the National Patient Safety Goals since 2005. Moreover, the medication reconciliation process is recognized as a vital intervention at every intersection in healthcare to ensure medication accuracy at care transitions as outlined in the World Health Organization's Action on Patient Safety (High 5s) initiative. Medication reconciliation should be the established standard of practice conducted at every care transition involving the prescription of new medicine, when adjustments to existing orders are made, or the addition of “home medications" and “non-prescription medications.” This practice guarantees the generation of the most precise and all-encompassing compilation of medication details (the best possible medication history) and should be communicated verbally and in written form with the patients, caregivers, and other health professionals involved of the treatment team. Additionally, the use of pharmacist intervention for patient education and/or medication reconciliation has shown to reduce medication errors after discharge and decrease readmission. Another tool is AHRQ’s Medication at Transitions and Clinical Handoffs (MATCH) toolkit, which provides step-by-step guidance for organizations to improve their medication reconciliation workflow.

In addition to robust medication reconciliation process, patient education is also acknowledged as a strategy with substantial influences on minimizing medication errors. Strategies on how staff can incorporate families in medication communications are included as part of safety practices across transitions of care.


Efficient inpatient transitions of care, centered on coordination, communication, and collaboration are imperative to maintain continuity and quality of care for the patient and family. Additionally, patients who feel heard and valued are more inclined to participate in their care, thereby enhancing patient safety, improving outcomes, and reducing the risk of adverse issues. Addressing these risks involves implementing standardized communication processes, ensuring robust medication reconciliation protocols, fostering interdisciplinary collaboration, and offering ongoing education and training for healthcare professionals. If the hospital Mr. H was at had implemented these processes, he may have had improved care such as ensuring his hearing aides were available to better engage with his care, and family engagement to ensure medical history and the medication reconciliation was accurate. Focusing on these aspects enables hospitals to elevate safety and quality of care, particularly during the critical and frequently precarious transitions of care.

Anna Satake PhD, MSN, GCNS, RN
Geriatric Clinical Nurse Specialist
Assistant Clinical Professor
Department of Geriatrics
UC Davis Health
Vanessa McElroy, MSN, PHN, ACM-RN, IQCI
Director, Care Transitions and Population Healthcare Management
UC Davis Health


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  2. Okoniewska B, Santana MJ, Groshaus H, et al. Barriers to discharge in an acute care medical teaching unit: a qualitative analysis of health providers' perceptions. J Multidiscip Healthc. 2015;8:83-89. [Free full text]
  3. Butler JI, Fox MT. Nurses' perspectives on interprofessional communication in the prevention of functional decline in hospitalized older people. Health Commun. 2019;34(9):1053-1059. [Available at]
  4. Malik M, Zehra Zaidi R, Hussain A. Health literacy as a global public health concern: a systematic review. J of Pharmacol & Clin Res. 2017;4(2):1-7. [Free full text]
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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