patient transitions

Question 1

common transition errors

Answer 1

not developing a comprehensive discharge care plan, not reconciling pt medication lists from one facility to another, not including the family in the planning process, not communicating and collaborating with the right people at the new facility, not getting in touch w/the right community resources to support the patient, not starting the planning process soon enough

Question 2

contributing factors of transition errors

Answer 2

use of hospitalists, staff does not always know drugs well enough to give instructions, inconsistent med review before discharge (duplicate RX’s, sent home on discontinued meds), incompatible computer systems, unclear role definitions (who makes the call, who does the education), myraid of insurance policies (what they cover, in network providors)

Question 3

monitor for health changes…

Answer 3

especially during the first 48-72 hrs post discharge