In an effort to reduce medical errors during transfers of care, Stephen Routledge, MPH, (Patient Safety Improvement Lead, Canadian Patient Safety Institute) and Michael Wong, JD, (Founder and Executive Director, Physician-Patient Alliance for Health & Safety) recently co-authored an article, “What doctors can do to prevent medical errors during transfer of care.”
The Joint Commission has emphasized the need for collaboration across the entire care continuum to prevent adverse events and patient deaths:
"Unfortunately, these transitions do not always go smoothly. Ineffective care transition processes lead to adverse events and higher hospital readmission rates and costs.4 One study estimated that 80 percent of serious medical errors involve miscommunication during the hand-off between medical providers. Problematic transitions occur from and to virtually every type of health care setting, but especially when patients leave the hospital to receive care in another setting or at home, according to experts on this issue. To reduce both readmission rates and adverse events, hospitals must improve the effectiveness of transitions of care in which they play a role."
In order to keep patients safe, clinicians should focus on three key points along the patient’s continuum of care:
- Upon admission
- During patient recovery
- Upon patient discharge
Mr Wong emphasized the need to ensure patient safety during recovery, saying, “We have heard of many instances of deaths following successful procedures.” He cited the cases of Logan Parker, who had undergone surgery for obstructive sleep apnea (OSA) with elements of central sleep apnea, and Tyler Ireland, who died of opioid-induced respiratory depression while on a patient-controlled analgesia (PCA) pump. Their stories told by their mothers can be heard by clicking on the link above or by going to the PPAHS YouTube Channel.
As well, Mr. Wong encouraged clinicians to share these five questions with their patients:
- Have any medications been added, stopped or changed, and why?
- What medications do I need to keep taking, and why?
- How do I take my medication, and for how long?
- How will I know if my medication is working, and what side-effects do I watch for?
- Do I need any tests and when do I book my next visit?
These five questions were developed by ISMP Canada, the Canadian Patient Safety Institute, Patients for Patient Safety Canada, the Canadian Pharmacists Association and the Canadian Society for Hospital Pharmacists to help patients and caregivers start a conversation about medications to improve communications with their health care provider.
Clinicians are encouraged to download a PDF version of these five questions here.
To read the article in the Medical Post, please click here (registration required).
To read a pdf of the article, please click here.
About Physician-Patient Alliance for Health & Safety
Physician-Patient Alliance for Health & Safety is a non-profit 501(c)(3) whose mission is to promote safer clinical practices and standards for patients through collaboration among healthcare experts, professionals, scientific researchers, and others, in order to improve healthcare delivery. For more information, please go to www.ppahs.org.
Attachments:
A photo accompanying this announcement is available at http://www.globenewswire.com/NewsRoom/AttachmentNg/9772ad4d-75d6-4058-b6e8-1190a9506dcd