By: NurseGuides.com
Since the turn of the century, medical error and tort reform have increasingly taken center stage in the healthcare debate. Patients, politicians, policy makers, and healthcare professionals struggle with the striking prevalence and consequences of medical error, whether it be a “near miss” or an error resulting in patient injury. The Institute of Medicine (IOM) defines medical error as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”
Among the problems that commonly occur during the course of providing healthcare are adverse drug events, improper blood transfusions, surgical injuries such as wrong site surgery, falls, burns, mistaken identity, and even death. Moreover, high error rates with more serious consequences are most likely to occur in intensive care units (ICUs), operating rooms, and the emergency department. The Quality of Health Care in America Committee of the IOM has concluded that it isn't acceptable for patients to be harmed by a healthcare system that's supposed to offer healing and comfort; a system that promises to do no harm. This increased proclivity toward medical errors both creates and fosters an environment of mistrust. It's because of concerns such as these that the matter of patient safety is now in the healthcare spotlight.
The consideration of patient safety first is central to every decision made and every action performed by healthcare professionals and other care providers at any level of the continuum, including in the patient's home. In great part, the patient safety movement is about being a team player. If the patient is at the center of our efforts then case management is a cornerstone in the support system of patient care. With patient safety increasingly “under the microscope,” the case manager's role as a multifunctional coordinator of care expands beyond the team and the patient/family members, into the community and to other providers of care. Effective communication and enhanced decision making can reduce the fragmentation of care that places patients at risk for medical error.
There are five main areas of patient safety upon which case managers exert their efforts on a daily basis. These areas center upon:
As patients are stabilized and transitioned through a hospital's system of care, there can be multiple handoffs of care. Because patient care is often fragmented, duplicative, and sometimes disorganized and improperly planned, the risk of “life-threatening” medical errors increases as the patient's exposure within the healthcare system increases.
Handoffs or care transitions shouldn't be an abrupt end of care previously provided, but rather considered to be a coordinated changeover for the patient to a new team of involved caregivers. With few mechanisms in place for coordinating care across settings, often no single provider or team assumes responsibility during transitions. If discharge planning truly begins at the time of admission, each care transition should ideally be a planned process, unless of course the transition is an emergent one. Collaboration and effective communication among team members, before, during, and after the “hand-off,” are crucial at each stage of the medical management process. These critical interactions offer opportunities for clinical interface that can promote patient safety and contribute optimally to the avoidance of life-threatening medical errors.
Fortunately there are mandated systems in place that help to support appropriate care transitions and hand-offs. These mechanisms were developed and implemented to ensure patient safety and regulatory compliance. Discharge planning is a component of various pieces of legislation at both the federal and state level; it's also the requirement of various accrediting bodies such as The Joint Commission.
The Federal Conditions of Participation are rules that hospitals must follow in order to participate in the Medicare or Medicaid programs. Hospitals must have in effect a discharge planning process that applies to all patients. The hospital's policies and procedures must be specified in writing and updated accordingly. Those conditions that relate to the discharge planning process were last published August 11, 2004, effective October 1, 2004 and can be found in Section 42 CFR 482.43 of the Social Security Act. They're listed as standards in the Federal Conditions of Participation. Some of these relate directly to care transitions.
Care, treatment, and services are provided through the successful coordination and completion of several processes that include:
The goal of this function is to define, shape, and sequence the processes and activities related to care delivery along the illness-to-wellness continuum. Over time the patient may receive a range of care in multiple settings from multiple providers. For this reason, it's important for the hospital to view the patient care it provides as part of an integrated system of settings, services, healthcare practitioners, and care levels that make up the continuum of care.
Although the presence of standards is crucial to establishing accountability, it's noteworthy that the standards primarily reflect the perspective of the sending institution, but not that of the receiving institution. For example, Joint Commission standards include language relating to the exchange of information during transfers; however, the language speaks globally to the sending facility. Clearly, both the sending and receiving team have individual responsibilities as well as joint responsibilities. It's incumbent upon both to ensure, through effective collaboration and communication, that the patient's transition is safe. Enhancing accountability begins with setting expectations for both the sending and receiving healthcare teams.
Transfers among care settings are common. Twenty-three percent of hospitalized patients over the age of 65 are discharged to another institution, i.e., a skilled nursing facility, and 11.6% are discharged with home healthcare. Unfortunately, an estimated 19% of patients discharged from a hospital to a skilled nursing facility are readmitted to the hospital within 30 days. While much of the literature addresses facility-to-facility transfers, or facility-to-home transfers, there's little written that addresses intra-institutional care transitions, which is unit-to-unit, or from one level-of-care to another level-of-care within the hospital setting.
