Transitions of care can be rife with communications issues – and subsequent adverse events. They are also a place where hospitalists can take the lead in making improvements.
“They are the team leaders, typically,” said Ana Pujols McKee, MD, the executive vice president and chief medical officer for The Joint Commission. “The hospitalist really owns this process of the transfer of this accurate information.”
To help, The Joint Commission has issued a new Sentinel Event Alert, which provides seven recommendations to improve the communication failures that can occur when patients are transitioned from one caregiver to another, as well as a Targeted Solutions Tool to put the recommendations into action.
“Every organization is challenged in communicating accurate and timely information regarding patients,” Dr. McKee said. “One of the riskiest transitions that patients go through is when they change levels of care from ICU to med-surg, or from the ER to ICU, OR to ICU, med-surg to home, and home to home care. All of those transitions inherently carry a certain amount of risk and are deeply reliant on the transfer of the right information at the right time to the right person.”
