8. The “Transition Confusion” – A dance sensation that is sweeping the nation

Transitions in care represent potential weak links that couple together the complex array of care options that patients may encounter as they traverse the modern healthcare system.
Errors in communication can occur at shift changes for nurses and physicians, especially house officers, between units within hospitals (in some systems multiple transfers between wards is the norm) and between facilities. Each of these transitions requires the transmittal of precise relevant information that enables the transition to go smoothly so that errors are anticipated and eliminated, or at least reduced to the bare minimum of risk. Failure to do so can have catastrophic consequences.
Ever been in a situation where you tell someone something and then later that day they deny or “forget” that you had mentioned one particularly important item? Well I find that happens pretty consistently, not because people have bad memories, but rather because communication its tricky and the more details we need to convey the greater the risk for error. The more patients to be discussed and the increasing complexity of such patients both contribute to risks in transitions.
Today, many institutions have established checklist-monitored protocols that govern the transitions between units and even between shift changes. Institutions that have adopted such strategies have seen reductions in errors related to transitions. Unfortunately that is not always the case when moving patients between institutions, especially if these institutions are not affiliated.
Case Study: When 99% ain’t enough of the right stuff
A 65-year old man, resident in a care home because of chronic incapacitating rheumatoid arthritis, psoriasis and lack of family members to provide care, was transferred to an acute care hospital because of persistent hematochezia, bright red blood in his stools, for tests to exclude colon carcinoma. He had a previous myocardial infarction but had been stable on low dose aspirin and an ACE inhibitor for two years. He was due to undergo a colonoscopy and possibly other studies depending on what was found. His records referred to his regimen for rheumatoid arthritis that included etanercept (Enbrel), and methotrexate in addition to a statin for hypercholesterolemia, and his cardiac meds.
After an assessment by anaesthesia and a standard bowel prep for 24 hours the patient was taken to the procedure room where he underwent a colonoscopy that revealed a fungating, infiltrative carcinoma 2.5 cms in diameter in the ascending colon 25 centimeters distal to the ileocecal valve. The patient was scheduled for surgery 72 hours later after obtaining consultations from nutrition support services, rheumatology, cardiology, dermatology, cardiac anaesthesia and psychiatry. It was envisioned that a right hemi-colectomy would be performed with resultant colostomy, so the stoma team was alerted.
For two days prior to surgery the patient complained of increasing arthritic pain and substantial weakness and the nurses noted a decreased attention span, one commenting in a nursing note that he seemed overly somnolent. On the day of surgery the patient appeared confused in the morning, but this concern was not communicated to the surgical team, and as no one on the anaesthesia team really knew the patient, no one paid much attention to this
Post operatively, the patient failed to recover as expected. He remained somnolent and incoherent and was found to be in profound electrolyte imbalance with severe hyponatremia. He suffered a cardiac arrest on the third post-operative day and could not be resuscitated.
A review of this unexpected death revealed that in addition to listed medications the patient had been taking prednisolone daily for two years for his severe rheumatoid arthritis. This information was missing from the transfer note from the care facility to the acute care hospital. The patient’s symptoms preoperatively were consistent with adrenal insufficiency, most likely due to chronic prednisolone therapy and associated adrenal suppression that made him vulnerable to surgery. The failure to provide steroid support during and after surgery were directly linked to his death.
A preventable death caused by a failure to communicate one medication during a transition in care between institutions…, and another grandfather bites the dust. Small mistake with enormous consequences; dance on!


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