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1 - 13 of 13
Cam H, Kempen TGH, Eriksson H, et al. BMC Geriatr. 2021;21(7):618.
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(12):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.

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care. Based on the success of this test, Patient Safe-D was incorporated as part of the Society of Hospital Medicine's Project BOOST (Better Outcomes for Older Adults through Safe Transitions) initiative which uses medication reconciliation, teach back and the Discharge Patient Education Tool (DPET) to help reduce medication-related errors. BOOST provides a full implementation toolkit to help institutions implement this and other programs to improve discharge education.

Manias E, Bucknall T, Woodward-Kron R, et al. Int J Environ Res Public Health. 2021;18(8):3925.
Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.
Massa S, Wu J, Wang C, et al. Jt Comm J Qual Patient Saf. 2021;47(4):242-249.
The objective of this mixed methods study was to characterize training, practices, and preferences in interprofessional handoffs from the operating room to the intensive care unit (OR-to-ICU). Anesthesia residents, registered nurses, and advanced practice providers indicated that they had not received enough preparation for OR-to-ICU handoffs in their clinical education or on-the-job training. Clinicians from all professions noted a high value of interprofessional education in OR-to-ICU handoffs, especially during early degree programs would be beneficial.
van Heesch G, Frenkel J, Kollen W, et al. Jt Comm J Qual Patient Saf. 2020;47(4):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(3):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.
Uong A, Philips K, Hametz P, et al. Pediatrics. 2021;147(4):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.
Kannampallil T, Lew D, Pfeifer EE, et al. BMJ Qual Saf. 2021;30(9):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.  

A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Altho

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for seniors and other high-risk patients. The social worker/nurse practitioner team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers. The program, known as Geriatric Resources for Assessment and Care of Elders (GRACE), improved the provision of evidence-based care; led to significant improvements in measures of general health, vitality, social functioning, and mental health; reduced emergency department visits, hospital admissions, readmissions, and total bed days; and generated high levels of physician and patient satisfaction. These successes have been across a variety of health system contexts, including: a VA medical center, primary care health centers, and as a part of a Medicare Advantage plan. A recent analysis found that the reduction in service usage saved the VA medical center $200k per year for the 179 veterans enrolled in GRACE. Another analysis in primary care health centers found that the program was cost neutral for high-risk patients in the first 2 years, and yielded savings by year 3.

The program was initially designed to serve low-income seniors, but has subsequently been replicated with different populations, including adults of all ages who are high risk, Medicare beneficiaries who are 70+ with multiple comorbidities, and older veterans following an emergent hospital admission and discharge home.

Sentinel Event Alert. 2006;35:1-4.
This alert emphasizes the importance of reconciling medications and supports implementation of this Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) National Patient Safety Goal. Note: This alert has been retired effective August 2016. Please refer to the information link below for further details.