Medication Safety During Transitions of Care:

The Importance of Checklists in Preventing Patient Harm

  • Laressa Bethishou, PharmD, APh, BCPS Chapman University School of Pharmacy
  • Olivia Lounsbury Patient Safety Movement Foundation
  • Donna Prosser, DNP, RN Patient Safety Movement Foundation

Abstract

There is a need to optimize patient safety as patients navigate through the healthcare system. With each transition of care, patients are vulnerable to changes that may cause adverse effects, including changes in their healthcare team, health status, and medications. The Centers for Medicare & Medicaid Services (CMS) defines a transition of care as “the movement of a patient from one setting of care to another.” While the concept itself may seem simple, this definition fails to capture the many potential handoff complications which classify these transitions as high risk for patients. With 67% of patients facing unintended medication discrepancies in the hospital and more than 40% of medication reconciliation errors resulting from miscommunications in handoffs, medication safety has become a leading priority for patients and caregivers. The World Health Organization articulated the need to improve communication specifically during points of transition. Differences in communication styles, distracting environments, and the lack of standardization are the primary factors contributing to the 80% of medical errors resulting from transitional miscommunication.

Author Biographies

Laressa Bethishou, PharmD, APh, BCPS, Chapman University School of Pharmacy

Laressa Bethishou (bethisho@chapman.edu) is assistant professor and director of co-curriculum, Pharmacy Practice, at Chapman University School of Pharmacy in Irvina, California. Her research interests include evaluating the impact of pharmacist interventions on high-risk patient populations, such as heart failure patients, asthma and COPD exacerbations, and pneumonia admissions.

Olivia Lounsbury , Patient Safety Movement Foundation

Olivia Lounsbury is a clinical intern at the Patient Safety Movement Foundation and a junior at Chapman University in Orange, California, where she is pursuing a double major in Health Science and Policy and Behavioral Studies.

Donna Prosser, DNP, RN, Patient Safety Movement Foundation

Donna Prosser is chief clinical officer at the Patient Safety Movement Foundation. She is a Fellow in the American College of Healthcare Executives and is board certified as a Nurse Executive by the American Nurses Credentialing Center and as a Patient Advocate by the Patient Advocate Certification Board.

 

References

Improving Transitions of Care. The Vision of the National Transitions of Care Coalition. National Transitions of Care Coalition. 2008.

Tam VC. Frequency, Type and Clinical Importance of Medication History Errors at Admission to Hospital: A Systematic Review. Can Med Assoc J. 2005;173(5):510–5.

PaSQ. Medication Reconciliation [Internet]. European Union Network for Patient Safety and Quality of Care. 2012 [cited 2019Dec27]. Available from: http://www.pasq.eu/Home.aspx

WHO. Medication Without Harm -Global Patient Safety Challenge on Medication Safety [Internet]. World Health Organization; 2017 [cited 2019Dec27]. Available from: http://www.who.int/patientsafety/medication-safety/en

Joint Commission. Joint Commission Introduces New, Customized tool to improve hand-off communications [Internet]. The Joint Commission. 2012 [cited 2019Dec27]. Available from: http://www.jointcommission.org/issues/article.aspx?Article=RZlHoUK2oak83WO8Rk CmZ9hVSIJT8ZbrI4NznZ1LEUk=

Birmingham P, Buffum MD, Blegen MA, Lyndon A. Handoffs and Patient Safety. West J Nurs Res. 2014;37(11):1458–78.

Jayaswal S. Evaluating safety of handoffs between anesthesia care providers. Ochsner J. 2011;11(2):99–101.

Hales BM, Pronovost PJ. The checklist—a tool for error Management and performance improvement. J Crit Care. 2006;21(3):231–5.

White RE, Trbovich PL, Easty AC, Savage P, Trip K, Hyland S. Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model. BMJ Qual Saf. 2010;19(6):562–7.

Walker I, Reshamwalla S, Wilson I. Surgical safety checklists: do they improve outcomes? Br J of Anaesth. 2012;109(1):47–54.

Catchpole K, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Ped Anesth. 2007;17(5).

Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, et al. Eliminating catheter-related bloodstream infections in the intensive care unit*. Crit Care Med. 2004;32(10):2014–20.

Pronovost PJ. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication—Invited Critique. Arch Surg. 2008Jan;143(1):18.

Vries END, Dijkstra L, Smorenburg SM, Meijer RP, Boermeester MA. The SURgical PAtient Safety System (SURPASS) checklist optimizes timing of antibiotic prophylaxis. Patient Saf Surg. 2010;4(1):6.

Changes in Medical Errors With a Handoff Program. N Engl J Med. 2015;372(5):490–1.

McLeod MC. Medication administration processes and systems—exploring the effects of systems-based variation on the safety of medication administration in the UK National Health Service. PHD thesis March 2013, UCL School of Pharmacy.

Mohsin-Shaikh S, Garfield S, Franklin BD. Patient involvement in medication safety in hospital: an exploratory study. Int J Clin Pharm. 2014;36(3):657–66.

Schwappach DLB, Wernli M. Barriers and facilitators to chemotherapy patients engagement in medical error prevention. Ann Oncol. 2010Aug;22(2):424–30.

Walker, I., Reshamwalla, S., & Wilson, I. (2012). Surgical safety checklists: do they improve outcomes? Br J Anaesth, 109(1), 47–54. doi: 10.1093/bja/aes175

Longtin Y, Sax H, Leape LL, Sheridan SE, Donaldson L, Pittet D. Patient Participation: Current Knowledge and Applicability to Patient Safety. Mayo Clinic Proceedings. 2010;85(1):53–62.

Eligible Professional Meaningful Use Menu Set of Measures Measure 7 of 9 [Internet]. Centers for Medicare and Medicaid Services; 2014 [cited 2019Dec27]. Available from: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/

Loftin E, Andrews D, Mikitarian G, Lamanna J. Zero Harm During Transition in Care From the Emergency Department to Medical/Surgical Units. J Nurs Care Qual. 2019;1.

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Published
2020-06-17
How to Cite
Bethishou, L., Lounsbury , O., & Prosser, D. (2020). Medication Safety During Transitions of Care:: The Importance of Checklists in Preventing Patient Harm. Patient Safety , 2(2), 8. Retrieved from https://patientsafetyj.com/index.php/patientsaf/article/view/med-safety-toc
Section
Patient Safety Initiatives
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