Patient Safety in Transitions of Care: Addressing Discharge Communication Gaps and the Potential of the Teach-Back Method

Introduction Effective communication in the transition of care is fundamental to improve patient safety and contribute to the reduction of adverse events [1]. A study carried out in 2014, in fifty-five hospital units in Portugal, under the “Evaluation of Patient Safety Culture in Hospitals”, concluded that patient safety culture is not yet widely acknowledged as a priority for health professionals [2], and that 70% of adverse health events occur due to communication failures among health professionals during the transition of care. Ineffective communication can be found in different health contexts, being more frequent during the transition of care, when it is essential to manage situations quickly and effectively. The peri-operative period, the ICU and emergency department are examples of contexts where communication processes are complex and prone to errors. Objective To know nurses opinion about the transition of care in the emergency department, as well as their knowledge on the patient safety. Materials and Methods This is a descriptive and exploratory study with a quantitative approach. Non-probabilistic and convenience sample. This study intends to answer the following research questions: What is the opinion of the emergency department nurses about the time of transition of care during shift change? Do nurses know the guidelines for patient safety in the care transition? A questionnaire was used as a data collection instrument. It consists of three parts: a first part on sample characterisation; a second part that seeks to know the opinion of nurses about the transition of care in the change of shift; and a third part, with the objective of assessing nurses' knowledge on patient's safety. The questionnaire was applied during the month of January 2019. Results Of the total of seventy questionnaires delivered fifty were returned, with a response rate of 67.57%. The sample is essentially composed of women (82%), with a mean age of 33.46 years. They have on average 10.67 years as nurses and 7.29 years as nurses in the emergency department. With regard to nurses' opinion on the transition of care during shift change, four domains were found, namely: Positive aspects of the nursing care transition moment; Negative aspects of the nursing care transition moment; Patient evaluation at the moment of nursing care transition; and management of the information obtained during the nursing care transition. Regarding nurses' knowledge on patient safety, three areas were identified: Knowledge of the guidelines on effective communication in the transition of care; Benefits of using a standard tool in the transition of care, and training in the area of patient safety. Discussion and conclusions: Nurses feel that there are a number of factors that interfere with the transition of care; there is irrelevant information that is transmitted in the moment of transition of care and the ISBAR methodology contributes to decision-making and critical thinking. It is important to promote team training in the area of patient safety. Nurses have the legal obligation to ensure continuity of care through effective communication, using existing resources, namely the ISBAR tool.

Early Impressions of the CLER Program: A Survey of the Designated Institutional Official Community.

Preventing medication errors in transitions of care: A patient case approach

Emergency Nurses Association Position Statement: Medication Management and Reconciliation in the Emergency Setting

During the past decade, patient safety issues during care transitions have gained greater attention at both the local and national level. Readmission rates to U.S. hospitals are high, often because of poor care transitions. Serious adverse drug events (ADEs) caused by an incomplete understanding of changes in complex drug regimens can be an important factor contributing to readmission rates. This paper describes the roles and responsibilities of pharmacists in ensuring optimal outcomes from drug therapy during care transitions. Barriers to effective care transitions, including inadequate communication, poor care coordination, and the lack of one clinician ultimately responsible for these transitions, are discussed. This paper also identifies specific patient populations at high risk of ADEs during care transitions. Several national initiatives and newer care transition models are discussed, including multi- and interdisciplinary programs with pharmacists as key members. Among their potential roles, pharmacists should participate on medical rounds where available, perform medication reconciliation and admission drug histories, apply their knowledge of drug therapy to anticipate and resolve problems during transitions, communicate changes in drug regimens between providers and care settings, assess the appropriateness and patient understanding of drug regimens, promote adherence, and assess health literacy. In addition, this paper identifies barriers and ongoing challenges limiting greater involvement of pharmacists from different practice settings during care transitions. Professional degree programs and residency training programs should increase their emphasis on pharmacists' roles, especially as part of interdisciplinary teams, in improving patient safety during care transitions in diverse practice settings. This paper also recommends that Accreditation Council for Pharmacy Education (ACPE) standards include specific language regarding the exposure of students to issues regarding care transitions and that students have several opportunities to practice the skills needed for effective care transitions. Moreover, reimbursement mechanisms that permit greater pharmacist involvement in providing medication assistance to patients going through care transitions should be explored. Although health information technology offers the potential for safer care transitions, pharmacists' use of information technology must be integrated into the national initiatives for pharmacists to be effectively involved in care transitions. This paper concludes with a discussion about the importance of recognizing and addressing health literacy issues to promote patient empowerment during and after care transitions.

Implementing quality improvement (QI) education during clinical training is challenging due to time constraints and inadequate faculty development in these areas. Quiz-based reinforcement systems show promise in fostering active engagement, collaboration, healthy competition and real-time formative feedback, although further research on their effectiveness is required. An online quiz-based reinforcement system to increase resident and faculty knowledge in QI, patient safety and care transitions. Experts in QI and educational assessment at the 5 University of California medical campuses developed a course comprised of 3 quizzes on Introduction to QI, Patient Safety and Care Transitions. Each quiz contained 20 questions and utilized an online educational quiz-based reinforcement system that leveraged spaced learning. Approximately 500 learners completed the course (completion rate 66-86%). Knowledge acquisition scores for all quizzes increased after completion: Introduction to QI (35-73%), Patient Safety (58-95%), and Care Transitions (66-90%). Learners reported that the quiz-based system was an effective teaching modality and preferred this type of education to classroom-based lectures. Suggestions for improvement included reducing frequency of presentation of questions and utilizing more questions that test learners on application of knowledge instead of knowledge acquisition. A multi-campus online quiz-based reinforcement system to train residents in QI, patient safety and care transitions was feasible, acceptable, and increased knowledge. The course may be best utilized to supplement classroom-based and experiential curricula, along with increased attention to optimizing frequency of presentation of questions and enhancing application skills.

ICU TRANSITION OF CARE

Factors associated with perceived medication safety during transitions of care in patients with cancer: A secondary data analysis of a cross-sectional survey.

Background and importance Accurate medication records are essential in preventing errors, avoiding harm, aiding diagnosis and treatment planning. Prescribing errors are more prevalent on hospital admission1 2Medicines reconciliation (MR), ‘the formal process in which healthcare professionals partner with patients to ensure accurate and complete medication information transfer at interfaces of care’, ensures accurate medication record generation.3 MR is undertaken to varying degrees in many institutions, by a variety of healthcare professionals, each with their own focus, priorities and methods.4 MR is a WHO patient safety priority outlined in the High 5s Project.3 Aim and objectives To determine views and opinions of doctors towards a pharmacist-led MR service in an acute hospital and to ascertain what doctors identify as MR barriers and facilitators. Material and methods A self-completion questionnaire using mixed methodology was conducted. This involved analysing data both qualitatively and quantitatively. Data were collected simultaneously. Inclusion criteria: all doctors working at the Mater Misericordiae University Hospital (MMUH). Exclusion criteria: none. Data were analysed on site using a password protected spreadsheet on Microsoft Excel. Detailed content and thematic analysis were performed to identify common concepts. A 10% proportion of the data was checked by an independent reviewer Results The positive impact on patient care and safety demonstrated by MR was acknowledged by 98% (n=50): 94% (n=49) agreed MR saved them time while 92% (n=48) recognised MR decreased their workload, 90% (n=46) of participants were satisfied with the MMUH MR service and 94% (n=49) agreed MR was accurate. Participants called for dedication of pharmacy resources to MR (88%, n=46), and service expansion to include all patients on admission, care transition and discharge was advocated by participants (79%, n=41; 86%, n=44; and 79%, n=41, respectively). The most important facilitator was verbal communication of MR discrepancies. The most important barrier was current service limitations. Thematic analysis identified four themes: patient safety (n=33), workload implications (n=9), MR usefulness (n=52) and service development (n=56). Conclusion and relevance Prescribers viewed the pharmacist-led MR service as a positive useful initiative, saving prescribers time, and increasing patient care and safety hospital wide. References and/or acknowledgements 1. Porcelli PJ, Waitman LR, Brown SH. A review of medication reconciliation issues and experiences with clinical staff and information systems. Appl Clin Informatics 2010;1:442–461. 2. FitzGerald RJ. Medication errors: the importance of an accurate drug history. Br J Clin Pharmacol 2009;67:671–675. 3. World Health Organization. Standard operating protocol assuring medication accuracy at transitions in care, 2014. 4. Barnsteiner JH. Medication reconciliation. In: Hughes RG, editor. Patient safety and quality an evidence-based handbook for nurses 2008;38:2–459. No conflict of interest.

Families Perception, Knowledge, and Psychological Stress of Transitions of Care From the ICU: Improving Transition of Care

Reconceptualizing Care Transitions Research From the Patient Perspective.

Improving care transitions: Optimizing medication reconciliation

The aim of this study is to explore the cognition and practice on transitional care during the transfer from intensive care unit to a general ward among health care professionals in China. Due to the significant differences in the medical and humanistic environment at home and abroad, the safety of patients during the transmission from intensive care unit to the general ward is often ignored when their conditions become stable. There are few qualitative studies on the cognition and practice on transitional care during the transfer from intensive care unit to the ward among health care professionals in China. With a qualitative research design, 20 medical and nursing staff in the neurosurgery intensive care unit and ward were interviewed from May 2021 to August 2021. NVivo 11.0 software was utilized for Colaizzi's (1978) method of data analysis. Based on data analysis, perceptions of transitional care, the influencing factors for transitional care and the recommendations for improving transitional care were obtained. To ensure the continuity of care and improve patient safety during the period from intensive care unit to a general ward in China, we should clarify the expectation for the content of intensive care unit transitional care services, establish the transitional nursing team, guide nursing work, standardize the handover mode and process from intensive care unit to the general ward, promote the communication and coordination of health care professionals and improve the transitional nursing security system from the perspective of institutional level. This study can be used as a guide to help health care professionals provide a reference for the comprehensive development of transitional care services and the formulation of targeted intervention measures during the transfer from intensive care unit to a general ward in China.

Patient safety is an important concept in resident education. To date, few studies have assessed resident perceptions of patient safety across different specialties. The study explored residents' views on patient safety across the specialties of internal medicine, general surgery, and diagnostic radiology, focusing on common themes and differences. In fall 2012, interviews of small groups of senior residents in internal medicine, general surgery, and diagnostic radiology were conducted at 3 academic medical centers and 3 community teaching hospitals in 3 major US metropolitan areas. In total, 33 residents were interviewed. Interviews used interactive discussion to explore multiple facets of patient safety. Residents identified lack of information, common errors, volume and acuity of patients, and inadequate supervision as major risks to patient safety. Specific threats to patient safety included communication problems, transitions of care, information technology interface issues, time constraints, and work flow. Residents disclosed that reporting safety issues was viewed as burdensome and carrying some degree of risk. There was variability as to whether residents would report safety threats they encountered. Residents are aware of threats to patient safety and have a unique perspective compared with other health care professionals. Transitions of care and communication problems were the most common safety threats identified by the residents interviewed.

In 2001, the Institute of Medicine (IOM) reported that inadequate handoffs are “where safety often fails first.” 1 Other groups quickly joined the call for improved handoffs. The Joint Commission in 2006 added a new National Patient Safety Goal: improve the effectiveness of communication among caregivers and require hospitals to “implement a standardized approach to ‘handoff’ communications, including an opportunity to ask and respond to questions.” 2 Also in 2006, the World Health Organization Collaborating Centre on Patient Safety (Solutions), the World Alliance for Patient Safety, and the Commonwealth Fund joined to launch the “High 5s” initiative, which includes prevention of patient care handoff errors.3 In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) enacted resident duty hour requirements to promote patient safety and resident well-being.4 However, these work restrictions have produced unintended consequences, such as an increase in frequency of handoffs, institution of night float systems, a shift mentality, and an increased risk of preventable adverse events associated with coverage by a physician from another team.5–,7 Further ACGME duty hour restrictions became effective in July 2011.8 For the first time, these included handoff requirements. Although referred to as “transitions of care,” the requirements mostly refer to handoffs (box 1). Box 1 Transitions of care (ie, shift-to-shift handoffs) in ACGME Common Program Requirementsa VI.B. Transitions of Care VI.B.1. Programs must design clinical assignments to minimize the number of transitions in patient care. VI.B.2. Sponsoring institutions and programs must ensure and monitor effective, structured hand-over processes to facilitate both continuity of care and patient safety. VI.B.3. Programs must ensure that residents are competent in communicating with team members in the hand-over process. VI.B.4. The sponsoring institution must ensure the availability of schedules that inform all members of the health care team of attending physicians and residents currently responsible for each patient's care. The first of the new ACGME requirements is to minimize patient care transitions, which is complicated by the fact that both the 2003 and 2011 resident duty hour restrictions are likely to increase the frequency of inpatient handoffs. Most institutions have not utilized a formal teaching program to teach handoffs to residents. The 2011 transitions of care language clearly calls for structured instruction, evaluation, and monitoring of handoffs. As a result, residencies across the country are struggling with how best to accomplish these new requirements. This editorial outlines a research agenda for shift-to-shift handoffs in medicine.