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.
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.
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.
Uong A, Philips K, Hametz P, et al. Pediatrics. 2021;147:e20200031.
Breakdowns in communication between clinicians and patients and their caregivers are common and can lead to adverse events. This article describes the development of the SAFER Care framework for written and verbal discharge counseling in pediatric units. The SAFER mnemonic reminds clinicians delivering discharge counseling to discuss safe return to school/daycare, activity restrictions, follow-up plans expected symptoms after discharge, when to return and seek care for symptoms, and who to contact with questions. Results from caregiver surveys indicate that the SAFER Care framework improved their comprehension of discharge instructions.
Patient safety is a concern throughout the entire process of care from admission to discharge. This article highlights the role of risk managers to assure that patients return to a home environment that can enable their safe recovery whether the discharge is advised or not.
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