Patient Care Transitions: a Becker’s 2017 Top 10 Patient Safety Issue

N.B. — This post is one in a series of ten, based on Becker’s Infection Control & Clinical Quality article 10 top patient safety issues for 2017 by Heather Punke & Brian Zimmerman and published on January 18, 2017 (

Patient care transitions. Patient handoffs are always a risky moment in a patient’s care journey, whether the move is from care team to care team or from acute care to post-acute care or to home. A study published in JAMA in December [2016} further solidified that truth, finding the end-of-rotation transition between resident care teams was associated with a significantly higher risk of in-hospital patient mortality.

Fortunately, several patient handoffs tools and checklists exist to strengthen this process, and an analysis of such protocols published in November 2016 in Human Factors: The Journal of the Human Factors and Ergonomics Society, showed those protocols do help. It found ‘good evidence for the general benefit of using handoff protocols, regardless of setting or protocol type.’”

Although the foregoing quote from the from the Becker’s Infection Control & Clinical Quality e-publication cited above notes that there is “… good evidence for the general benefit of using handoff protocols …,” nevertheless these protocols increase cognitive overload on clinical staff during high-stress and time-critical periods in the management of patients during staff transition. As described in the posts entitled PSMF APSS Challenge 6: Hand-off Communications and IT-enabled Medical Practice & Healthcare Delivery Transformation, automation of the handoff  checklist in the context of an app that automatically retrieves and forces its update, based on time-sensitive electronic health record (EHR) monitoring to ensure performance of medical orders in a timely manner, can avoid patient adverse events including fatalities.

An IT solution compliant with the Cloud Healthcare Appliance Real-Time Solution as a Service Reference Architecture (CHARTSaaS RA) can enable automatic action performance monitoring and also complete and accurate handoff communications. Please validate this proposition to your own satisfaction by reviewing the details of CHARTSaaS and the CHARTSaaS RA by reviewing these presentations, and then by imagining a CHARTSaaS-enabled IT solution:

Healthcare providers and their patients will benefit significantly from appreciating and then applying a CHARTSaaS RA-compliant IT solution. To do so will mitigate medical mistakes (currently the  third leading cause of patient deaths, per Makaray and Daniel,, thereby minimizing  patient adverse events; and also will optimize clinical case outcomes while maximizing the cost-effectiveness of care and treatment and accelerating the accrual of medical knowledge.



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