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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.


This article was originally published in Patient Safety, volume 2, issue 2, in 2020.


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