Special Report: Improving care transition communication

Latest SREs include a care transition issue

Strategies can be found in "Safe Practices"

The Washington, DC-based National Quality Forum (NQF) Board has updated its list of serious reportable events (SREs) in health care, adding one that directly affects how hospitals handle care transition communication.

Specifically, NQF has added a new SRE that states, "Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results."

The SREs, which were first published in 2002, are updated and refined based on the evolution of the evidence, as well as in reaction to adverse events and recommendations from organizations and individuals, says Melinda L. Murphy, RN, MS, senior director, NQF performance measures department.

The SRE related to failure to follow up or communicate lab, pathology, or radiology test results began as a recommendation regarding failure to follow-up or communicate clinical information, Murphy notes.

"People gave us feedback on the initial draft report where we had the more broad statement related to clinical information," she explains. "And at that point during the comment period we received feedback that suggested we could make a more refined, clear, and specific statement."

The NQF's SREs number 29 in all. These cover a range of health care areas, representing preventable errors and events, including pressure ulcers, patient falls, and serious medication errors. These are used by states and organizations in reporting systems and best practice standards.

"Well over half the states now report adverse events that occur to patients, and many of those states use the NQF-endorsed series of SREs for their reporting," Murphy says.

Here's a hypothetical example of a serious reportable event that might match the new standard during a care transition moment: A patient is in the hospital to have a series of tests related to a particular condition and symptoms. Then the patient is discharged before all of the test results are available, Murphy says.

"Somewhere along the line, those tests go missing in transmission from the hospital to my doctor's office or in a letter that was supposed to go to the patient," she adds.

The missing report says the patient has a treatable cancer. But because the patient and the patient's physician never receive the report, the patient's cancer worsens, and the patient dies, Murphy says.

In another hypothetical example, a newborn is discharged from the hospital with an elevated bilirubin level not communicated and followed up. This results in kernicterus, which can lead to serious neurological complications, such as brain damage.

"As a consumer in this country I would like those kinds of events to be reported for the learning and prevention strategies that can occur," she says.

"From the very beginning, that has been the intention of the SREs — to find a way to capture events, know what types are occurring, how frequently they are occurring, to identify the most frequent and harmful events in order to identify solutions across organizations and states," she explains.

The National Quality Forum already has a list of safe practices that addresses communication and hand-offs across providers and organizations, Murphy notes.

"The intent is to improve communication about what goes on with a patient from one provider to another to ensure continuity," she explains. "Underlying all of this is prevention of these events, which cause serious injury and sometimes death."

The NQF's latest list of safe practices, published as the "Safe Practices for Better Healthcare – 2010 Update," includes some guidance on how to prevent problems involving care transition and discharge communication. Its care transition safe practice guidance includes the following:

Safe Practice 12: Patient Care Information — Ensure that care information is transmitted and appropriately documented in a timely manner and in a clearly understandable form to patients and to all of the patient's healthcare providers/professionals, within and between care settings, who need that information to provide continued care.

Safe Practice 13: Order Read-Back and Abbreviations — Incorporate within your organization a safe, effective communication strategy, structures, and systems to include the following:

— For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person who is receiving the information record and "read-back" the complete order or test result.

— Standardize a list of "Do Not Use" abbreviations, acronyms, symbols, and dose designations that cannot be used throughout the organization.

Safe Practice 15: Discharge Systems — A "discharge plan" must be prepared for each patient at the time of hospital discharge, and a concise discharge summary must be prepared for and relayed to the clinical caregiver accepting responsibility for post discharge care in a timely manner. Organizations must ensure that there is confirmation of receipt of the discharge information by the independent licensed practitioner who will assume the responsibility for care after discharge.

Safe Practice 17: Medication Reconciliation — The healthcare organization must develop, reconcile, and communicate an accurate patient medication list throughout the continuum of care.


• Melinda L. Murphy, RN, MS, Senior Director, Performance Measures, National Quality Forum, Washington, DC. Email: press@qualityforum.org. Telephone: (202) 783-1300. Website: www.qualityforum.org.