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Transition Zones and Health Care Errors

by Edward J. Kroger, MD, JD on February 16th, 2011

Transition zones are places where the properties or behavior of something undergoes a radical change. Examples are found everywhere – in biology (beaches, wetlands), physics (boiling points, light passing through prism, loss of laminar flow), human relations (births, job changes, teen years), geography (borders of countries), politics (leadership changes). Much of what is interesting in life (for better or worse) takes place in these transition zones. Scientists and explorers find them fascinating.

It should come as no surprise then that health care experts and risk managers have begun to turn their attention to patient care transition zones – office to ED, ED to floor, ED to home, floor to ICU, hospital admission to home, etc. Uncoordinated transitions between sites of care and caregivers, even within the same institution, have been linked to higher hospital readmission rates, medical errors, duplication of services, and the wasting of resources. For example, a study by Dr. Martin Were published in the September 2009 Journal of General Internal Medicine found that discharge summaries failed to mention 84% of labs with pending results (including 72% of tests requiring treatment changes). And 33% of the discharge summaries failed to even indicate the physician who would be following up with the patient. Many, if not most of our firm’s malpractice cases involve a lack of continuity between health care providers or care areas (e.g., the reason for ordering a test in the ED not communicated to floor when patient admitted).

An excellent background article on care transition zones is One Patient, Many Places: Managing Health Care Transitions, Part I: Introduction, Accountability, Information for Patients in Transition written by Eric A. Coleman, MD, MPH and Peter D. Fox, PhD, on behalf of the HMO Care Management Workgroup. Further information can also be found at The Care Transitions Program and Care Transitions Quality Improvement Organization Support Center.

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