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.
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.
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.
Volpi E, Giannelli A, Toccafondi G, et al. J Patient Saf. 2021;17:e143-e148.
Medication errors are a common and significant causes of patient harm. This retrospective study examined regional prescription registry (RPR) data at a single Italian hospital at 4 comparison points, pre-admission, admission, hospitalization, and post-discharge. Researchers identified 4,363 discrepancies among 14,573 prescriptions originating from 298 patients with a mean age of 71.2 years. Approximately one third of the discrepancies (1,310) were classified as unintentional and the majority (62.1%) of those were found when comparing the prescriptions during the transition from hospital discharge and the 9-month follow up. The study points to the need for enhanced communication between hospitalists and primary care providers at the hospital-home interface.
Kannampallil T, Lew D, Pfeifer EE, et al. BMJ Qual Saf. 2021;30:755-763.
Prior research has found that intraoperative anesthesia handovers can increase patient morbidity and mortality. However, this retrospective cohort study, focused on pediatric surgical patients treated, found that intraoperative anesthesia handovers were not associated with adverse postoperative outcomes.
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