Background: Unplanned readmissions in the U.S. healthcare system cost over $15 billion annually, a burden that increasingly impacts health systems as more patients transition to fully capitated models [1-2]. Despite evidence supporting the protective effect of post-hospitalization visits with primary care providers (PCPs), patient completion rates of these visits remain low [3-5]. Barriers include provider [...]

Background: Diagnostic errors frequently represent significant adverse events that can occur in any medical setting, particularly in rushed handovers and constrained timing. Cases that result in emergency hospitalization at the time of the initial outpatient visit are more likely to have complex or serious patient conditions and more detrimental diagnostic errors. Our study investigated diagnostic [...]

Background: Transitioning from inpatient to outpatient care is high-risk, often associated with harm from incomplete or ineffective communication of clinical information [1]. In one report, 41% of patients had at least one pending study at the time of discharge, 43% of which were abnormal and 9.4% potentially actionable [2]. The discharge summary is a ubiquitous [...]

Background: Transition of care, particularly at the point of discharge, is a pivotal part of the patient’s healthcare journey, carrying substantial risks to safety and quality of care. Whether a patient is discharged to home, an outpatient rehabilitation center, or a skilled nursing facility, each transition introduces opportunities for errors. Errors may include inaccurate medication [...]