Page 53 - 2022 Risk Basics - Systems

SVMIC Risk Basics: Systems

Care Transitions

Traditionally, hospital-based care accounts for the highest costs
associated with medical care. A significant percentage of hospital

readmissions are preventable. Many factors contribute to a patient’s
likelihood of being readmitted, including miscommunications between

patients or caregivers and medical teams regarding medications and
other discharge instructions. A 2016 study indicates communication

failures in U.S. hospitals and medical practices contributed to 1,744
deaths over a five-year period. Communication failures increase the
13
risk of patient and family dissatisfaction, which is a leading contributor
to professional licensure complaints and is estimated to contribute to 30

percent of all malpractice claims. Miscommunications are often driven by
ineffective or inconsistent systems.

As with follow-up appointments, it is recommended that physicians
have a tracking system in place to alert them to those patients who

have failed to make or keep appointments following discharge from the
hospital. Often times, patients discharged from the hospital are not even

established patients in the office practice. Although the practice may
have a process in place for scheduling follow-up appointments with

discharged patients during business hours, there are circumstances
that may result in a discharge after the office is closed. This necessitates

the establishment of a consistent process to verify that appointments
have been made for all discharges from the hospital. Because there may

be competing priorities and staffing considerations which affect the
hospital’s ability to arrange these appointments, it is important to avoid

relying on hospital staff to complete this task. Instead, the discharging
physician should communicate this information to staff at the office. Then,

a designated employee should verify that each discharged patient has

13 The Joint Commission, Sentinel Event Alert “Inadequate hand-off communication”, Issue 58, September 12,
2017

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