Safety During Transitions of Care

Patient care is defined in terms of the provider as well as the setting of care. The provider of care is generally the physician and nurses. The setting of care can be a home, hospital, skilled nursing facility, or many other settings. When a patient changes provider or care setting there is a risk to patient safety throughout the transition. During transitions, these patients are at risk for medical errors, service duplication, inappropriate care, and critical elements of the care plan “falling through the cracks.” About 40% of patients who are transitioned from the hospital to home experience at least one medical error. During transitions of care, patients are at risk of adverse drug events and hospital readmission.

Adverse Drug Events

Adverse drug events (ADEs) are defined as any injuries resulting from medication use, including physical harm, mental harm, or loss of function. When transitioning care settings patients often experience a change of drug that is prescribed to them, oftentimes a discontinuation. This discontinuation is dangerous to patients' health, potentially causing an adverse drug event.

Hospital Readmission

Currently, nearly 20% of Medicare beneficiaries experience readmission to the hospital within 30 days. Some reasons for readmission include premature discharge, inadequate post-discharge support, insufficient follow-up, therapeutic errors, adverse drug events or other medication-related issues, failed handoffs, complications during procedures, nosocomial infections, pressure ulcers, and falls. Although not all readmissions can be prevented, many are due to inadequate care or supervision and can be prevented with increased contact with previous providers.

Safety during transitions can be increased with the help of a patient advocate to keep in contact with providers and insure the patient is receiving adequate care. Patient advocates help to oversee all aspects of a patient’s care to prevent medical errors due to oversight.