ED to inpatient transfers; high rates of adverse events/near misses

By  |  May 20, 2009 | 

The transition from the ED to the inpatient unit is a very vulnerable time for patients. In this single institutional survey of ED and inpatient physicians (or PA’s), 29% reported a patient of theirs had experienced an adverse event or near miss due to inadequate communication during the transition from ED to inpatient. Qualitative analysis of the errors found multiple sources of error, including: communication (no communication, key content omitted, limited interaction, and conflicting expectations), unclear assignment of responsibility, environment (ED overcrowding and workload), and IT (information not readily available to inpatient team) (abstract). Although the high rate of adverse events and near misses is discouraging, it is encouraging to see that most of these error sources are relatively easily modifiable. By implementing hand-off tools (performed in a less distracted environment) that transmit standardized information, and creating an IT system that is accessible to all care providers, many of these can errors can be mitigated. Many of these are included in the elements of performance of JCAHO’s National Safety Patient Goal 02.05.0.1.

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About the Author:

Danielle Scheurer
Dr. Scheurer is a clinical hospitalist and the Medical Director of Quality and Safety at the Medical University of South Carolina in Charleston, South Carolina, and is Assistant Professor of Medicine. She is a graduate of the University of Tennessee College of Medicine, completed her residency at Duke University, and completed her Masters in Clinical Research at the Medical University of South Carolina. She also serves as the Web Editor and Physician Advisor for the Society of Hospital Medicine.

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