High-Risk Handoffs in Patient Care Transitions

Care transitions, whether from hospital to home or between departments, can be particularly vulnerable times for patients, due to increased safety risks. It can also leave healthcare organizations open to various liability exposures. Issues like medication errors or complications and adverse events, like falls or infections, can result from poor patient transitions.

“Communication failures between medical providers can lead to delayed treatment, and even mortality risk,” said Alleen Wilson, Senior Risk Control Manager at Safety National. “Patients at highest risk, particularly elderly patients and patients with complex conditions, must be actively involved in their care plan during each transition. Each discipline should clearly explain their role, outline the care plan moving forward and review any changes to medications, equipment or post-discharge instructions. When patients are unable to fully participate, a family member or caregiver should be included to ensure understanding, continuity, and safety across settings.”

Here, we explore factors that contribute to poor care transitions, the most at-risk settings, and the complications that can arise.

Most At-Risk Care Settings

Each stage of a patient’s transition following an injury, particularly serious injuries, requires considerable communication, covering everything from diagnoses, lab results, and medication management to red flag symptoms, advance directives, and more. At-risk transitions can include:

• Emergency room (ER) to inpatient
• Intensive care unit (ICU) to step-down
• Hospital to home
• Discharge to rehabilitation facility

A patient in emergency or intensive care may require more frequent communication between medical teams, but complications can occur at any phase when care coordination fails, requiring readmission. In fact, a study conducted at five home health agencies in the U.S. found that 70% of observed hospital-to-home health transitions involved at least one safety issue. The most frequently identified issues were unsafe home environments, medication issues, incomplete information, and a lack of understanding of care plans.

Contributing Factors

Patient-centered care relies on consistent, effective communication among medical teams. However, communication errors can happen, and when there are significant gaps, serious consequences can result. Appropriate documentation processes can help maintain clear and accurate transition arrangements between care plans. Effective communication also relies on adequate patient and caregiver education, often involving medication instructions and discharge summaries.

Another contributing factor to transition complications is socioeconomic status, including a patient’s access to ongoing care, supportive structures that assist in their care, and the safety of their home environment. One review found that patient safety and satisfaction increased when local healthcare services were contacted before discharge, thereby ensuring preemptive care coordination.

Complications

When patient care transitions are mismanaged, whether through miscommunication or lapses in communication, the outcome can result in delayed recovery. Poor handoffs between medical providers can lead to missing or delayed information. This can include inaccurate medication lists, where high-risk medications can lead to dangerous complications. Poorly communicated discharge instructions can lead to confusion among patients and caregivers, leaving them unable to manage in a home health care setting.

One study notes that nearly 20% of adult and elderly patients were affected by adverse drug events following a hospital discharge. Depending on the severity of such events, rehospitalization, or even death, can occur.

It is critical to note that these transition stages are opportunities to reduce patient and organizational risk by closely following established communication strategies. Resiliency in these vulnerable periods depends on timely detection and mitigation if a patient’s status suddenly changes or if an error occurs.