After reading Dr. Edward R. Sobel’s thoughtful piece on medical errors published by Delaware Online, I thought I’d discuss one of the items he mentioned in his article. In discussing medical errors and how to avoid them, Dr. Sobel mentioned the prevalence of medical errors occurring during hospital shift changes, patient transfers from hospital to an extended care facility, or a patient’s transfer back to the care of a family physician. I suspect most people don’t think about these times as prone to medical error through human miscommunication. These are all preventable errors if communication protocols are followed. However, we know through experience that many preventable medical errors still occur during these times of patient transfer.
More than a decade ago, the Institute of Medicine estimated that 98,000 patients die each year from medical error. I wonder how many have died due to medical error during a patient transfer or shift change in a hospital or extended care facility? The statistic is worth examining in order to reduce the number of fatalities during this time.
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