Page 38 - 2021 Risk Reduction Series - Communication Part One

SVMIC Risk Reduction Series: Communication

each year in the U.S. are not completed: patients opt out,
8
scheduling gets jumbled, critical information is either not sent
or not received, communication breaks down, and the systems

relied upon are incompletely designed to keep track of what
did or did not transpire. Beyond inefficiency, mishandled
9
referrals represent mistakes that can hurt and kill patients
through missed or delayed diagnoses, delays in treatment, and

other lapses in patient safety. Unlike tracking systems for lab
and diagnostic imaging, which have received much attention,

emphasis on tracking referrals is lagging.

To address a concern of this scale and potential for patient
harm, CRICO and the Institute for Healthcare Improvement/

National Patient Safety Foundation joined forces to convene
a panel of experts (including EHR vendors) and produced a

comprehensive outline of practical steps organizations can
take to reduce the risk of referrals-related medical errors. That

document, Closing the Loop: A Guide to Safer Ambulatory
Referrals in the EHR Era, identifies nine potential patient-safety
10
gaps in the referrals process, along with the expert panels’
specific recommendations for closing those gaps.

An illustration of the Nine Steps of the Closed-Loop EHR
Referral Process is shown in the following figure:

8 Weiner M, Perkins AJ, Callahan CM. 2010. Errors in completion of referrals among older urban
adults in ambulatory care.6(1):76–81
9 Barnett ML, Song Z, Landon BE. 2012. Trends in physician referrals in the United States,
1999–2009. Archives of Internal Medicine. 172(2):163–170
10 Hoffman, Jock. Toward an Ideal Referral Process, CRICO podcast, November 29, 2017

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