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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.

Song Y, Hoben M, Norton PG, et al. JAMA Netw Open. 2020;3.
The authors surveyed over 4,000 care aids from 93 urban nursing homes in Western Canada to assess the association of work environment with missed and rushed essential care tasks. During their most recent shift, over half of care aids (57.4%) reported missing at least one essential care task and two-thirds (65.4%) reported rushing at least one essential care task. Work environments with better work culture and more effective leadership were associated with fewer missed or rushed care tasks.
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
Following a hospital stay for a broken arm and dislocated shoulder, an older man was discharged to a skilled nursing facility (SNF) for rehabilitation. Providers were concerned about his ability to live independently given results of cognitive and living skills assessments performed during the hospital stay. Although the hospital social worker had begun the process of applying for home care and meals for the patient, the SNF discharged him home with no access to care, food, or his medications.
Scott AM, Li J, Oyewole-Eletu S, et al. Jt Comm J Qual Patient Saf. 2017;43.
Fragmented care transitions may lead to adverse events due to poor provider communication, disjointed continuation of care, and incomplete patient follow-up. In this study, site visits were conducted at 22 healthcare organization across the United State to determine facilitators and barriers to implementing transitional care services. Identified facilitators included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Results suggest how institutions may wish to prioritize strategies to facility effective care transitions.
Jackson PD, Biggins MS, Cowan L, et al. Rehabil Nurs. 2016;41:135-48.
Transitions are a complicated and vulnerable time for patients, particularly for those with complex care needs. This review examines the literature around care transitions and insights from patient and family advisory councils. The authors recommend standardizing the process for veterans with complex conditions and suggest focus on the use of real-time information exchange, documented care plans, and engaging patients and their families in transitions.
Allan J, Ball P, Alston M. Rural Remote Health. 2008;8:835.
Drawing from qualitative interviews with pharmacists and social workers, investigators determined that access to rural health services is affected by individual concerns about privacy and confidentiality, and by the reputation and value system of the health care worker.
Following a swallowing study, a speech pathologist recommends that a patient receive nothing by mouth, due to a high risk of aspiration. However, because the report is misfiled, no NPO order is implemented.