Dealing with Patient Transfers

Medical errors during the critical patient transfers (care transitions) time period are an area of growing concern. Errors across the continuum of care account for 13% of all events. [1]

Background

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) specifically targets medical errors relating to care transitions by virtue of its National Patient Safety Goal to "accurately and completely reconcile medications across the continuum of care" (Ref 2). It is the responsibility of individual health care institutions and organizations to develop and implement safe clinical practice policies with regard to care transitions. Many are in the preliminary stages of leveraging their clinical information systems and/or computerized physician order entry (CPOE) to address these patient safety concerns.

The Patient Transfer Process

Patient transfers occur during hospital admission from the emergency room, transfer between different services (i.e. medical, surgical, sub-specialty), and transfer between different levels of care (i.e. intensive care unit to general medical ward, operating room to recovery unit, etc.)

The transfer process should include the following elements:

1. Determination if transfer will require a change of service and/or providers.
2. Determination if transfer will require an alternative level of care.
3. Communication of information to the accepting providers, if necessary.
4. Review of medications and non-medication orders.
5. Reconciliation of medication and non-medication orders.
6. Writing and/or discontinuing orders prior to patient transfer.
7. Physical transfer of patient to new location, if necessary.
8. Update patient status in clinical information system(s) with all relevant information relating to transfer.

How can computerized physician order entry (CPOE) help?

Computerized physician order entry (CPOE) can facilitate and promote safe patient transfer practices with respect to the medication review and reconciliation (Ref 3). For example, Poon et al describe an effort to leverage their institutions available clinical information systems to develop an integrated application supporting medication reconciliation across the spectrum of patient care activities from admission to discharge (Ref 4). Importantly, the authors recognize the need to develop a common solution to support different clinical workflows and multiple CPOEs within their organization.

In general, any inaccurate, unclear, and/or inactive order may present a safety concern particularly when new providers assume care of a patient. CPOE can provide a reconciliation function with respect to non-medication orders as well as medication orders.

Finally, CPOE may facilitate information transfer by being the primary data capture point during the care transition process. Medical information transfer is now routinely performed by “sign-outs” between physicians. Accuracy, flexibility, and portability are identified as key elements. Standardization of information necessary for safe patient transfer may include active medical problems, active medications, code status, important labs, pending studies, etc. Computerization of sign-outs can help organize the transfer of vital patient information (Ref 5). Implementation of such a computerized process at a point which promotes optimal workflow should enhance safety while retaining usability.

References

1. http://www.jcipatientsafety.org/fpdf/psp/PatientSafetyArticles/S3-PS-02-03.pdf
2. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/
3. http://www.jcipatientsafety.org/14711/
4. Poon et al. Design and Implementation of an Application and Associated Services to Support Interdisciplinary Medication Reconciliation Efforts at an Integrated Healthcare Delivery Network. J Am Med Inform Assoc. 2006;13:581-592
5. Organizing the transfer of patient care information: the development of a computerized resident sign-out system. Surgery. Jul 2004;136:5-13