Patient safety: Transition of care, teamwork, and communication errors

Modern patient safety strategies are systems-based, recognizing that adverse events often stem from system failures in communication, coordination, and organizational workflows rather than individual errors.

When we think of patient safety, it's helpful to separate when and why errors occur. Transitions of care are among the highest risk moments in health care.

Transitions of care occur when a patient's care moves between clinicians or clinical settings. These include hospital admissions, departmental transfers, shift changes, and discharges to outpatient care.

Transitions of care are particularly prone to error because they involve multiple clinicians, complex clinical information to convey, time pressure, and lack of standardization.

The consequences of transition of care errors can be significant, including hospital readmissions, delayed treatment, and preventable complications.

Let's look at a patient case to better understand how this process is exposed to vulnerabilities. Ms.

Garcia is a 72-year-old female with a history of type 2 diabetes mellitus and hypertension. She presents to the emergency department from a nursing home with fever, dysuria, and flank pain.

She is diagnosed with pyelonephritis and admitted for intravenous antibiotics during her hospitalization. Miss Garcia improves clinically, but her blood glucose levels remain elevated, requiring adjustments to her insulin regimen.

On day 3 of the hospital stay, she was deemed clinically stable for discharge with oral antibiotics. Her insulin dosing was modified given her improved oral intake.

Doctor Scott, Miss Garcia's physician, discusses these medication changes, but due to time constraints, he rushes through the discharge process, and her instructions were incomplete.

There was no structured handoff to her care team at the nursing home. Shortly after discharge, a urine culture obtained during Mrs.

Garcia's hospital stay returned showing resistance to the prescribed oral antibiotic. This result was not reviewed, and her care team at the nursing home was not aware it was pending.

Two days later, Miss Garcia returns to the emergency department with fever, nausea, and fatigue. I wasn't sure how much insulin I should be taking, she tells the care team.

She is hyperglycemic with a persistent infection. Upon readmission, Nurse Kelly notes that the patient's heart rate is elevated and her BP is trending downward.

However, she delays reporting these findings because she was unsure of the urgency and felt intimidated by Doctor Scott.

Other members of the care team, including the medical and nursing students, followed her lead. The patient's clinical status change was not shared with the oncoming team.

As a result of the delay, the patient's condition worsened, and she was later found to have sepsis, requiring transfer to a higher level of care.

As you can see in Ms. Garcia's case, the discharge process represents a high risk transition of care.

During this transition, critical medication instructions and pending lab results were not properly conveyed, leading to confusion and inadequate treatment.

OK, while the transition of care in Ms. Garcia's case created a high risk moment, the harm occurred due to several contributing factors such as communication, teamwork, authority gradient, and situational awareness.

Communication is essential for accurate transfer of clinical information. Miscommunication occurs when information is not accurately passed on, received, or understood.

During Miss Garcia's discharge, her new insulin recommendations were not effectively communicated, contributing to confusion, incorrect home dosing, and hyperglycemia upon readmission.

Additionally, when she was readmitted, her nurse did not communicate with the physician or other members of the team about her deteriorating vitals.

These instances of miscommunication caused both incorrect treatment and a delay in care, leading to patient harm. Next, teamwork is important for coordinating care, ensuring accountability and supporting collaborative decision making.

It also fosters a shared sense of responsibility for patient outcomes. Looking back at Ms.

Garcia's case, several breakdowns on teamwork contributed to her clinical decline. First, there was no coordinated effort to involve the nursing home care team at discharge.

Having a complete and accurate discharge summary with follow-up instructions sent to her outpatient care team at the nursing home could have ensured proper follow-up, particularly close monitoring of blood glucose levels and culture data.

Another example of poor teamwork occurred at readmission when Ms. Garcia's status worsened.

There was no coordinated response from all members of the team, including medical and nursing students who did not escalate concerns that the patient was worsening.

Now let's discuss the authority gradient which refers to the hierarchical differences in power and perceived authority among members of a health care team.

While some degree of hierarchy is necessary for a team to function, an excessive or steep authority gradient can discourage open communication, leading to patient harm.

In our patient case during Miss Garcia's readmission, Nurse Kelly felt intimidated by Doctor Scott, perhaps due to hierarchical dynamics, and delayed notifying him of the patient's vital sign changes, contributing to the patient's decline and preventing timely intervention.

Decreasing the authority gradient means reducing hierarchical barriers so all team members feel empowered to speak up about patient concerns.

Encouraging open communication, actively seeking input, and responding respectfully to concerns are essential strategies for reducing the negative effects of hierarchy.

Finally, there's situational awareness. This is the ability to recognize relevant clinical information, understand what it means, and anticipate how a patient's condition may change.

It's a key part of patient safety and health care, especially during transitions of care when there are multiple competing demands such as shift changes, administrative needs, patient volume, and documentation responsibilities.

In Miss Garcia's case, early indicators of sepsis were present during her readmission, including an increasing heart rate and falling BP.

Although these changes were noticed, they were not acted on or escalated, demonstrating a breakdown in the team's situational awareness and communication.

Effective situational awareness requires team members to share a collective understanding of the patient's condition and communicate promptly.

OK, now that we've discussed the key factors that contribute to patient harm in health care, what can we do to prevent these errors?

That's where the IPASS communication tool comes in. It's a widely used handoff tool that uses a standardized checklist to reduce medical errors.

IPASS stands for illness severity, patient summary, action list, situational awareness and contingency plan, and synthesis by receiver.

Let's go over each one quickly. Illness severity is a brief description of the patient's status, such as stable or unstable.

The patient's summary describes the patient's known diagnoses and treatment plans. The action list summarizes the next steps that the clinician receiving the handoff needs to take.

Situational awareness and contingency plans include what to watch for and what to do if the patient's clinical presentation changes.

Lastly, synthesis by the receiver means the receiving clinician confirms understanding and can ask questions. Overall, structured handoff tools like iPass improve clarity, reduce error, and support safer patient care during transitions.

In Ms. Garcia's case, using I pass at discharge could have clarified her medication changes and highlighted pending urine culture results for follow up.

It would also have improved communication between her hospital and care team at the nursing home. Lastly, let's discuss SBAR, a standardized communication tool used in healthcare to share information clearly and efficiently, especially in urgent situations.

SBAR stands for situation, which is a brief statement of the current issue, background, including any relevant clinical history, assessment, referring to your clinical evaluation and recommendation, meaning what you want done.

In Miss Garcia's case, her S bar might look like this situation Miss Garcia has developed tachycardia and her BP is dropping.

Background, she was admitted for pyelonephritis. Assessment I'm concerned she may be clinically deteriorating, and recommendation I would like you to reassess her now.

Overall, by organizing information into a structured format, SB reduces ambiguity and supports effective clinical decision making.

It also provides a consistent framework that encourages speaking up in a clear and professional manner, reducing hierarchical barriers, and improving patient safety.

All right, as a quick recap, transitions of care are high risk periods in health care harm occurs when communication fails, teamwork breaks down, authority gradients discourage team members from speaking up, and situational awareness is lost.

IPAS is a structured tool used when handing off patients, and it stands for illness severity, patient summary, action list, situational awareness and contingency plan, and synthesis by receiver.

SBA is used when communicating urgent issues. It describes the situation, background, assessment, and recommendation.

Both tools strengthen communication, support teamwork, mitigate hierarchical barriers, and improve situational awareness.