Improving the safety and quality of care transitions

AORN Journal, July, 2008 by Carolyn M. Clancy

As patients move from one health care setting to another, the role of nursing in care and decision-making processes is essential to ensure positive patient outcomes. The role of nursing during care transitions, however, is not fully understood or recognized. As health care organizations and quality improvement groups seek to change processes to improve safety and reduce errors, the role of nursing in care transitions demands closer attention.

Care transitions are defined as the processes of transferring a patient either within one care setting or between two different care settings. The potential for medical errors increases when more than one health care provider or site of care is involved in providing services to a patient. Patient safety research demonstrates that the cumulative effect of mistakes that occur during care transitions can result in significant patient harm or even death.

CHANGING NEEDS PROMPT TRANSITIONS

Patients' needs change over time. Whether patients' health needs are chronic or acute, their conditions can reflect a new diagnosis, symptoms without a diagnosis, or a sudden change in health status. Health care operates as a continuous process that involves a variety of health care providers, including nurses, physicians, and pharmacists, many of whom work in shift rotations and in different delivery settings. Patients often move from one provider or site of care to another, particularly when their needs are complex. Examples of transitions include the following:

* One shift ends and a new shift begins, with different clinicians managing a patient's care.

* A patient is brought by ambulance to the emergency department and is subsequently admitted to the hospital.

* A patient is transferred from an acute care setting to a skilled nursing facility or to his or her home.

* A patient is transferred from an intensive care unit to end-of-life or palliative care.

Quality improvement strategies for enhancing care transitions often require changes in the process of care delivery by nurses, physicians, and other clinicians. Encouraging appropriate patient involvement, however, is also an increasingly important consideration. This involvement is a Joint Commission National Patient Safety Goal. (1) Instead of treating a patient as an object or a number that needs to move from one site to another, the patient safety goal calls for transitions that are patient-centered, can support patient choices and goals, and can benefit from an interdisciplinary team approach.

Patient-centered transitions also offer opportunities for patient education and participation by determining patient goals and preferences. Because quality improvement strategies that seek to improve transitions can involve nurses, physicians, managers, and patients, performance standards and measures that demonstrate improvement and provide assurance of continued quality of care delivery should be established.

MEDICATION ERRORS AND TRANSITIONS

Medication errors are frequently associated with admission, transfer, and discharge. (2) To reduce the likelihood of these errors, many organizations are implementing medication reconciliation programs that double check patient orders to verify proper medication use and identify potential unintended variances. Together with health information technology, medication reconciliation enables nurses and other clinicians to reduce the incidence of medication errors.

New processes involving medication reconciliation are showing impressive results. In one study, 75% of potential medication errors at the time of a patient's transition to or from the hospital were intercepted because of a standardized medication reconciliation process. (3)

Nurses perform a variety of roles that involve dispensing medications to patients; therefore, they also can be active participants in a hospital's medication reconciliation process. Nurses are typically involved with physicians, nurse practitioners, pharmacists, and patients in coordinating, filling, and administering medication orders.

NEED FOR ACCURATE, TIMELY INFORMATION

Care transitions frequently involve verbal or written transmission of patient information, thus increasing the potential for information to be lost or miscommunicated. As patients move from one clinician or one site of care to another, active communication (ie, communication that does not leave room for interpretation and reflects changing circumstances) provides nurses with the appropriate knowledge base with which to provide quality care. This type of information transfer should be the standard during patient and shift hand offs to reduce or eliminate the potential for errors caused by missing or inaccurate information. In acute care and other settings where changes in a patient's condition or needs can occur on a daily or even hourly basis, clear and up-to-date information is critical.

Communication failures were found to be the root cause of failure in almost 70% of all sentinel events reported to the Joint Commission. (4) There are various reasons for these communication failures. Clinicians may not possess effective written or verbal skills, or they may lack formal training in effective hand offs. Also, the hand-off process has not been standardized, creating the risk that clinicians will provide inconsistent levels and quality of information. The quality and safety of the hand-off process has been shown to be variable, unstructured, and error-prone. (5)