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Buitrago I, Seidl KL, Gingold DB, et al. J Healthc Qual. 2022;44:169-177.
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 WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Mueller SK, Shannon E, Dalal A, et al. J Patient Saf. 2021;17:e752-e757.
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.
Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She also serves as the Program Director for the Emergency Medical Services (EMS) Fellowship and was past-president of the National Association of EMS Physicians. We spoke with her about her experience working in emergency medical systems and safety concerns particular to this field.
To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid.
Alabdali A, Fisher JD, Trivedy C, et al. Air Med J. 2017;36:116-121.
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.
Goldberg SA, Porat A, Strother CG, et al. Prehosp Emerg Care. 2017;21:14-17.
Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) are known to be suboptimal. This record review of 90 EMS-to-ED handoffs at a single academic medical center found that essential information was often omitted. The authors suggest that further training is needed to enhance the quality of these handoffs.
Sujan MA, Chessum P, Rudd M, et al. J Health Serv Res Policy. 2015;20:17-25.
Patient handoffs are a major challenge for patient safety, especially when patients move between different units or organizations. Analysis of 270 handoffs between ambulances to emergency departments (EDs) and EDs to inpatient units uncovered many tensions and themes, such as how competing patient flow priorities can impact the quality of handoffs.
Dawson S, King L, Grantham H. Emerg Med Australas. 2015;25:393-405.
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.

Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.  

This special issue contains articles exploring safety improvement efforts in emergency medical services.
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
Kingston, ACT: Australian Medical Association; 2006.
This report outlines best practices for patient transfer and shares experiences from the field for Australian physicians and health care organizations that seek to improve their handoff processes.