Executive Summary

Case managers may think their job doesn’t involve patient safety, but they promote safety by ensuring a safe discharge and are in a position to see safety breaches and mistakes all over the hospital.

• CMS includes discharge planning in its worksheets for surveyors to use to assess a hospital’s compliance with Medicare Conditions of Participation.

• Because they work with patients from admission to discharge, case managers know which clinicians are competent, those who are not, and may observe safety breaches like failure to wash hands and leaving the catheter in too long.

• Case managers should spend enough time with their patients to know their situations at home and their support systems and use the information to create workable and safe discharge plans.

• Hospitals should create an environment and a culture where case managers and other clinicians feel comfortable speaking up when they see safety breaches.


You may think that because you’re a case manager, you aren’t directly involved in patient safety. You couldn’t be further from the truth, experts say.

“Case managers may not think of themselves as a patient safety officer, but a lot of what they do is part of patient safety. Case managers promote patient safety through ensuring a safe discharge, improving outcomes, and preventing unnecessary readmissions,” says Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH.

Case managers are another pair of eyes in the system, adds Patrice Spath, RHIT, principal in Brown-Spath & Associates, a Forest Glen, OR healthcare quality consulting firm. “As they move throughout the hospital, they see what’s going on and can act as a safeguard by identifying patient safety breaches and potential mistakes,” Spath says.

“If there is anyone on the healthcare team who has a wide-angle view of what is going on with patients, it’s the case manager. The case manager’s perspective is extremely valuable because they watch over patients from admission to discharge. Any case manager who works in a hospital for any amount of time knows where the strengths and the weaknesses are,” adds John D. Banja, PhD, professor, department of rehabilitation at Emory University in Atlanta and a medical ethicist at Emory’s Center for Ethics.

The Centers for Medicare & Medicaid Services (CMS) is placing a lot of emphasis on patient safety, Spath points out. “Patient safety issues have financial implications for hospitals, but they also affect patient satisfaction. Studies have shown that patients who feel safer are more satisfied with their hospital experience,” she says.

Discharge planning is the topic of one of the three worksheets CMS developed for state and federal surveyors to use when they assess hospitals’ compliance with the Medicare Conditions of Participation, Dill Calloway says. The other two worksheets focus on infection control and performance improvement.

“It’s easy to see that infection control and performance improvement are a part of patient safety, but discharge planning may not fit into everyone’s idea of patient safety,” she says.

However, if a patient who is discharged from the hospital doesn’t know how to take care of his or her surgical wound and ends up with an infection that requires hospitalization, it’s a patient safety issue, she points out.

“Healthcare is a very complex system being run by well-meaning but imperfect human beings. The opportunity for disaster is always there in the hospital. It’s a very dynamic and complex environment that always runs imperfectly,” Banja says.

“Very few catastrophes are caused by a single person doing something stupid. They occur when multiple people make multiple mistakes and they all glom together. The road to patient safety is to be able to see errors and halt their potential for disaster before they cause harm,” he adds.

Case managers have the opportunity to see how everyone on the staff relates to or interfaces with patients, Banja says. “They know which healthcare professionals are competent, and when the system is working well. They also know people who take shortcuts and engage in other behavior that could harm patients. They know because they are in a position to observe what is going on and they should be constantly concerned about maintaining a safe environment,” he says.

The Affordable Care Act and the shift to pay for performance bring a heightened awareness of patient safety and the role that case managers play, says Patrice Sminkey, RN, chief executive officer for the Commission for Case Management Certification.

“Case managers have the opportunity to engage the healthcare team, the patient, and his or her support system to ensure that patients are safe in the hospital and have a safe discharge and transition,” she says.

As they work with patients, case managers should involve patients and family members in hospital safety issues, Spath says.

Case managers can help patients and family members recognize red flags that may indicate a safety concern and speak up about them, she advises. For instance, encourage them to say something to the nurse if the medication for the patient looks different or if the patient seems to be getting worse, she says.

Case managers also should be on the lookout for red flags indicating that a patient is at risk, Spath says. “For instance, failure to progress is a particularly problematic area that generates a lot of litigation. Often when there is a sentinel event, it is because of failure to notice that the pain is not well controlled or that the patient is not getting better. The case manager is another person who should be watching for red flags that indicate the patient is not responding to treatment,” she says.

One of the most common hospital-acquired conditions is catheter-associated urinary tract infections, Spath points out. Case managers should mention it to staff if it appears from the medical record that the catheter has been in too long, she adds.

Case managers should also intervene in cases of domestic violence, suspected child abuse, and elder abuse, Dill Calloway says. “Case managers have the resources to get child services or elder services involved or arrange a safe house for families. Ensuring that patients have a safe place to go back to is another facet of patient safety,” she says.

A lot of what case managers are doing to keep patients from being readmitted falls under patient safety and that starts with a thorough assessment, Sminkey says.

Case managers should complete a solid assessment and be keenly aware of what the patient needs after discharge, Sminkey says.

“Knowing patient needs and potential risks up front helps the hospital staff make sure the patient is safe and allows us to improve the transition when the patient moves to another setting,” she says.

Even though the patient assessment often calls for documentation by checking off boxes, it can’t be a replacement for assessing the whole person, including psychosocial and emotional needs, Sminkey says.

Spend time with your patients and find out everything you can about their family dynamics, their home environment, and their support system. Ask the patients what kind of place they live in, if there are stairs and how many. Ask if they can cook their own meals and if they feel comfortable taking a shower without assistance, Dill Calloway suggests.

Include the need for home modifications in your assessment, Dill Calloway says. For instance, if someone has limited mobility, ask about the stairs in his or her home. Does the family need to have a wheelchair ramp installed?

Case managers should be aware of the patient’s risk for falls and reinforce the fall prevention instructions, Spath says. “Case managers often spend more time talking with the patient and family than the nurse. If they feel the risk for falls is higher than the record indicates, they should speak up,” she says.

“Patients are at higher risk for an adverse event when they move from one setting to another and it’s up to case managers to ensure a safe transition,” Sminkey says.

Start by identifying patients who need a discharge evaluation, Dill Calloway says, adding that the CMS surveyor worksheets look at whether case managers make their patients aware that they can request a discharge evaluation and that their physician can request one, she says.

“During the hospital stay, case managers should assess and reassess patients for discharge needs. It’s not sufficient just to come in and spend five minutes going over a checklist,” Dill Calloway says.

Consider the whole person and his or her support system when you create a discharge plan, Sminkey says. “When case managers educate the patient, they should know who else to engage in the process. It may not be the family. It could be a neighbor or someone else in the community,” she says.