Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.

This single-site survey of resident and attending physicians across multiple specialties uncovered multiple safety vulnerabilities in the process of interhospital transfer. Investigators found that physicians and patients were both dissatisfied with timing of transfers and that critical patient records were missing upon transfer. These issues raise safety concerns for highly variable interhospital transfer practices.

Interfacility transport of critically ill patients may be performed by physician-led teams or by paramedics without direct physician involvement. This systematic review attempted to determine if transport by paramedics alone was safe for patients, but researchers found only a small number of studies with limited characterization of the types of adverse events encountered in this situation.

This review calls for research to understand challenges related to time, resources, and interprofessional relationships that affect information transfer between prehospital and hospital staff before implementing standard methods and tools for this type of handoff.

This focus group study with emergency medical services personnel identified several potential ways to improve the quality of handoffs between paramedics and emergency department staff. A structured handoff tool has been developed to address this known safety hazard.

Handoffs between care settings can lead to adverse events. This literature review analyzed 17 studies of handoffs between prehospital first responders and emergency department (ED) staff. Safety gaps detected included communication barriers, lack of a structured communication tool, and unclear identification of the receiving clinical staff. The authors suggest that a structured handoff tool could improve first responder–ED handoffs. A past AHRQ WebM&M commentary discussed communication failures between providers and highlighted a need for standard handoff protocols.

Although interhospital air transport is generally safe, this analysis of quality assurance reports found that most errors involved communication problems.

Prior research has documented errors in handoffs between ambulance and emergency department personnel. This study reports on the development and initial implementation of a structured tool for use at this handoff.

This systematic review found that communication, efficiency, and appropriateness are key factors in ensuring high quality and safe non-emergency transport services.

This review found that handoff errors are common between ambulance personnel and the emergency department, and there is a need for standardization of handoff responsibilities and development of structured handoff protocols.

This article describes a case where lack of clarity in communication contributed to the death of a patient and highlights strategies to prevent similar failures, including read back and critical assertion.

The authors describe the retrieval and transfer of critically ill patients from one environment to another and provide recommendations for making this process as safe and reliable as possible.

The authors interviewed interns to understand communication failures with patient transfer processes. They suggest improvements for verbal sign-out and propose that these improvements be used in designing educational programs on effective communication.

The authors studied the efficacy of using critical incident reviews to improve care in neonatal emergency transfer service.