Background: Communication has been cited as the most common root cause in sentinel events, with failed patient care handoffs contributing to an estimated 80% of serious preventable adverse events. Handoffs to sub-acute care such as nursing homes are at particularly high risk for communication breakdown given high patient complexity and comorbidity. Our healthcare system includes [...]

Background: Patients are discharged home on medications different than those they were taking before admission.  New and discontinued medications as well as dosage changes contribute to medication-related adverse events.  Purpose: To help address this problem, interns in our program developed a standard process during their quality improvement (QI) curriculum to ensure that at least 95% [...]

Background: Inter-hospital transfer (IHT, the transfer of patients between acute care hospitals) exposes patients to risks of discontinuity of care and remains a largely unstudied process of care. In this study, we aimed to investigate patient experiences with IHT.Methods: Interview guides were developed using themes extracted from prior research along with expert opinion and stakeholder [...]

Background: Patients are often transferred between hospitals to provide access to required specialty services. However, prior research suggests that transfer destinations are often chosen based on institutional relationships rather than solely on patient need. In this national study, we evaluated the appropriateness of transfer, as measured by the frequency of required specialty services available at [...]

Background: Care transitions between hospitals, nursing homes, and home are a vulnerable time for patients.  Given the increasing elderly population and the shortage of primary care physicians with training in geriatrics or nursing home care, there is a growing need to identify organizational systems to optimize physician practice, enhance quality of care and increase educational [...]