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A 72-year-old man was prescribed three new prescriptions upon discharge from the hospital because his blood pressure was elevated. The doctor instructed him to stop taking his former blood pressure medication and to start taking the new ones. When asked by a nurse if he had any questions about the new medications, he replied that he understood, and didn’t have any questions.

A few days later the man suffered a fall at home and went to the Emergency Department where his blood pressure was extremely elevated. When asked what medications he was taking to control his blood pressure he reported that, just as the doctor had instructed, he had stopped taking the medication he had previously been on. He also said that he had gone to the pharmacy to pick up the new medications but learned the price was too much for him to pay and that he planned to pick them up at the end of the month. 

A transition of care is the movement of a patient from one health care setting or provider to another. Examples are: discharge from hospital to home, admission from home to a hospital, or movement from one unit to another within the hospital. Transitions of care typically involve the coordination of care and “hand-off” communication. This is where important information can sometimes be overlooked, missed, or miscommunicated.

One study estimated that as many as 80 percent of serious medical errors involve miscommunication during the hand-off between medical providers.1

Keeping the patient at the center of their own care is essential. Communication failures and other gaps in the transition of care can leave someone vulnerable to error. One tried and true method of addressing these gaps is to fully engage patients and families in their care; and to empower and educate patients and families about their plan of care.

The University of Vermont Medical Center employs numerous strategies to help reduce problems around transitions of care. Initiatives such as bedside nurse hand-off, patient centered rounding, secure access to patient medical records, and Accountable Care Units, are just a few examples. The one constant through any transition of care is you, the patient, and your family.

Here are a few examples of how you can partner with your health care team to prevent gaps in transitions of care:

  • Don’t be afraid to ask questions about what will happen next
    • Don’t settle for an answer you don’t fully understand
    • If something doesn’t sound as though it will work for you, tell your doctor or nurse
    • Know who to call if something doesn’t go as planned
    • Have a friend or family member listen to instructions with you
    • Clarify activity or bathing instructions
    • Understand your dietary recommendations
    • Repeat back instructions you hear using your own words
  • Understand your follow-up appointments and why they are needed
  • Ask “What are the red flags I should be watching for?”
  • Medication changes are a particular area to focus on:
    • Be sure you understand any new medications, what they are for, and how you should take them
    • Know what medications you will stop taking
    • Know what medications you will continue taking
    • Keep a list of your medications with you and keep it up to date
    • Click here for a Medication Wallet Cardyou can use to keep track of your medications
  • Sign up for access to your health record to stay informed about your care at MyHealth Online
  • If transitioning from hospital to home:
    • Expect that you will be given verbal and written instructions prior to leaving
    • Clarify instructions that you don’t understand before you leave
    • Have emergency telephone numbers near you at home
    • Use night-lights in bedrooms and bathrooms to prevent falls at night
    • Wear non-slip socks, shoes or slippers
    • Keep walkways clear of clutter
    • Confirm your transportation needs prior to discharge

Access the National Transitions of Care Coalition site for additional information and resources.

This week we have been posting daily blogs with perspectives on safety and letting you know how you can partner with us on patient safety. Answer the question at the end of each daily blog and be entered to win a $25 Amazon Gift Card made possible by our partnership with the New England Federal Credit Union. Thank you for joining us in recognizing National Patient Safety Awareness Week and for your participation!

Partner with us, speak up, and don’t leave patient safety to chance!


The Office of Patient Safety at the University of Vermont Medical Center

  1. Solet DJ, et al: Lost in translation: challenges and opportunities in physician-to-physician communication during patient hand-offs. Academic Medicine, 2005; 80:1094-9

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