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

Leave A Comment

About the Author: Danielle Scheurer

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.


Related Posts

By  | September 20, 2018 |  0
Have you ever wondered if there’s a correlation between Gore-Tex® (Think: rain jacket material) and Social Media? No!? Well, I have… It turns out there may be more commonality between these topics than what one might imagine. You see, Bill Gore (the company’s founder and CEO) recognized a particular number in his manufacturing plants: 150. […]
By  | September 12, 2018 |  1
I just heard. A colleague, a man of integrity and warmth, a hard-working physician with ideals, ethics and many valued contributions, has taken his own life. His perspectives may have differed from mine at times, but every interaction was infused with respect. He was a good man. Much has been written about the rate of […]
By  | June 4, 2018 |  4
The question of appropriate ward garb is a problem for the ages. Compared to photo stills and films from the 1960s, the doctors of today appear like vagabonds. No ties, no lab coats, and scrub tops have become the norm for a number (a majority ?) of hospital-based docs—and even more so on the surgical […]