The PSNet Collection

Handoffs and teamwork: a framework for care transition communication.

Save to Library

Webster KLW, Keebler JR, Lazzara EH, et al. Jt Comm Qual Patient Saf. 2022;48:343-353.

Effective handoff communication is a key indicator of safe patient care. These authors outline a new model for handoff communication, integrating three theoretical frameworks addressing relevant inputs (i.e., individual organizational, environmental factors), mediators (e.g., communication, leadership), outcomes (e.g., patient, provider, teamwork, and organizational outcomes), and adaptation loops.

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

Save to Library

Farnborough, UK: Healthcare Safety Investigation Branch; June 2022.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This interim report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

Identifying Safety Events in the Prehospital Setting

Save to Library

May 16, 2022

This piece focuses on measuring and monitoring patient safety in the prehospital setting.

Post-Acute Transitional Services: Safety in Home-Based Care Programs.

Save to Library

April 27, 2022

Post-acute transitions – which involve patients being discharged from the hospital to home-based or community care environments – are associated with patient safety risks, often due to poor communication and fragmented care. This primer outlines the main types of home-based care services and formal home-based care programs and how these services can increase patient safety and improve health outcomes.

Safety of elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical data warehouse.

Save to Library

El Abd A, Schwab C, Clementz A, et al. J Patient Saf. 2022;18:230-236.

Older adults are at high risk for 30-day unplanned hospital readmission. This study identified patient-level risk factors among patients 75 years or older who were initially hospitalized for fall-related injuries. Risk factors included being a male, abnormal concentration of C-reactive protein, and anemia. Discharge programs targeting these patients could reduce 30-day unplanned readmissions.

Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes

Save to Library

February 24, 2022

Residents living in nursing homes or residential care facilities use common dining and activity spaces and may share rooms, which increases the risk for transmission of COVID-19 infection. This document describes key patient safety challenges facing older adults living in these settings, who are particularly vulnerable to the effects of the virus, and identifies federal guidelines and resources related to COVID-19 prevention and mitigation in long-term care. As of April 13, 2020, the Associated

Assessment of requests for medication-related follow-up after hospital discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective chart review.

Save to Library

Cam H, Kempen TGH, Eriksson H, et al. BMC Geriatr. 2021;21:618.

Poor communication between hospital and primary care providers can lead to adverse events, such as hospital readmission. In this study of older adults who required medication-related follow-up with their primary care provider, the discharging provider only sent an adequate request for 60% of patients. Of those patients that did not have an adequate request, 14% had a related hospital revisit within 6 months.

Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues.

Save to Library

Malevanchik L, Wheeler M, Gagliardi K, et al. Jt Comm J Qual Patient Saf. 2021;47:775-782.

Communication in healthcare is essential but can be complicated, particularly when there are language barriers between providers and patients. This study evaluated a hospital-wide care transitions program, with a goal of universal contact with discharged patients to identify and address care transition problems. Researchers found that the program reached most patients regardless of English proficiency, but that patients with limited English proficiency experienced more post-discharge issues, such as difficulty understanding discharge instructions, medication concerns and follow-up questions, and new or worsening symptoms.

Interventions to improve communication at hospital discharge and rates of readmission: a systematic review and meta-analysis.

Save to Library

Becker C, Zumbrunn S, Beck K, et al. JAMA Netw Open. 2021;4:e2119346.

Discharge from the hospital represents a vulnerable time for patients. This systematic review assessed the impact of discharge communication on hospital readmissions, adherence to treatment regimen, patient satisfaction, mortality, and emergency department visits 30 days after hospital discharge. Findings suggest that improved communication at discharge reduced 30-day hospital readmissions and increased adherence to treatment regimen.

Health literacy-related safety events: a qualitative study of health literacy failures in patient safety events.

Save to Library

Morrison AK, Gibson C, Higgins C, et al. Pediatr Qual Saf. 2021;6:e425.

Limited health literacy can lead to patients or caregivers misunderstanding care instructions. Researchers examined safety events occurring at one children’s hospital over a nine-month period and found that health literacy-related events accounted for 4% of all safety events. Health literacy-related events generally involved problems with medication (e.g., unclear discharge medication instructions, conflicting instructions), system processes (e.g.., failures to address language barriers), and discharge and transitions (e.g., unclear equipment information, unclear instructions about upcoming tests).

A scoping review of communication tools applicable to patients and their primary care providers after discharge from hospital.

Save to Library

Spencer RA, Singh Punia H. Patient Educ Couns. 2021;104:1681-1703.

Communication failures during transitions of care can threaten safe patient care. Although this systematic review identified several tools to support communication between inpatient providers and patients during transitions from hospital to home, the authors did not identify any existing tools to support the post-discharge period in primary care.

Project BOOST Increases Patient Understanding of Treatment and Follow-up Care

Save to Library

May 26, 2021

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

Interprofessional and intraprofessional communication about older people's medications across transitions of care.

Save to Library

Manias E, Bucknall T, Woodward-Kron R, et al. Int J Environ Res Public Health. 2021;18:3925.

Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

Save to Library

Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2022;31:278-286.

Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.

Engineering care transitions: clinician perceptions of barriers to safe medication management during transitions of patient care.

Save to Library

Hannum SM, Abebe E, Xiao Y, et al. Appl Ergon. 2020;91:103299.

Discharge can be a vulnerable time for patients, particularly older adults taking multiple medications. Through interviews with clinicians from 10 professional roles, researchers identified three key strategies to promote safe medication management at hospital discharge: (1) streamlining medication reconciliation across care settings, (2) building patient capacity and engagement, and (3) redesigning the transitional process. Aligning clinician and patient care transition goals using these three strategies may better prepare patients to safely self-manage their medications at home.

Incidence and variables associated with inconsistencies in opioid prescribing at hospital discharge and its associated adverse drug outcomes.

Save to Library

Kurteva S, Habib B, Moraga T, et al. Value Health. 2021;24:147-157.

Harms related to prescription opioid use are an ongoing patient safety challenge. Based on data from one hospital between 2014 and 2016, this cohort study found that nearly 50% of hospitalized patients were discharged with an opioid prescription, and 80% of those prescriptions were among patients discharged from a surgical unit. Opioid-related medication errors were more common in handwritten discharge prescriptions compared to electronic prescriptions; electronic prescriptions were associated with a 69% lower risk of opioid-related medication errors.

The association of nursing home characteristics and quality with adverse events after a hospitalization.

Save to Library

Field TS, Fouayzi H, Crawford S, et al. J Am Med Dir Assoc. 2021;22:2196-2200.

Transitioning from hospital to nursing home (NH) can be a vulnerable time for patients. This study looked for potential associations between adverse events (AE) for NH residents following hospital discharge and NH facility characteristics (e.g., 5-star quality rating, ownership, bed size). Researchers found few associations with individual quality indicators and no association between the 5-star quality rating or composite quality score. Future research to reduce AEs during transition from hospital to NH should look beyond currently available quality measures.

Interprofessional training and communication practices among clinicians in the postoperative ICU handoff.

Save to Library

Massa S, Wu J, Wang C, et al. Jt Comm J Qual Patient Saf. 2021;47:242-249.

The objective of this mixed methods study was to characterize training, practices, and preferences in interprofessional handoffs from the operating room to the intensive care unit (OR-to-ICU). Anesthesia residents, registered nurses, and advanced practice providers indicated that they had not received enough preparation for OR-to-ICU handoffs in their clinical education or on-the-job training. Clinicians from all professions noted a high value of interprofessional education in OR-to-ICU handoffs, especially during early degree programs would be beneficial.

Improving handoff by deliberate cognitive processing: results from a randomized controlled experimental study.

Save to Library

van Heesch G, Frenkel J, Kollen W, et al. Jt Comm J Qual Patient Saf. 2020;47:234-241.

Poor handoff communication can threaten patient safety. In this study set in the Netherlands, pediatric residents were asked to develop a contingency plan for patients received during handoffs and asked to recall information from that handoff five hours later. Results indicate that engaging in deliberate cognitive processing during handoffs resulted in better understanding of patients’ problems, which could contribute to improved patient safety.

Racial/ethnic disparities in interhospital transfer for conditions with a mortality benefit to transfer among patients with Medicare.

Save to Library

Shannon EM, Zheng J, Orav EJ, et al. JAMA Network Open. 2021:4(3);e213474.

This cross-sectional study examined whether racial/ethnic disparities in interhospital transfers (IHT) for common medical diagnoses such as heart failure, acute myocardial infarction, stroke, and sepsis, impact mortality outcomes. The authors analyzed 899,557 patients and reported that Black patients had lower odds of IHT compared to White patients, while Hispanic patient had higher odds of IHT compared with White patients. The authors propose several possible explanations including differences in Black and Hispanic willingness to transfer, impact of insurance status and reimbursement rates, coding inaccuracies, and other complex dynamics for their findings.

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users