Care Transitions: A Threat and an Opportunity for Patient Safety

redoubled its efforts to improve patient safety. The aviation industry has frequently been held up as a model for clinicians to emulate as we seek to revise our philosophy and our approach to reducing errors in medical care. Who can argue with the results? The aviation industry rightfully prides itself on identifying and stopping errors before they occur by using ongoing team training in a blame-free culture. As a result of comprehensive strategies put into place starting in 1950, aviation fatalities had dropped by 80% by 1990 despite a huge increase in air traffic volume during that period. Thanks to Federal Aviation Administration and National Transportation Safety Board policies and the training programs followed by professional pilots, travel-happy Americans can be confident about the safety of their major air carriers. Borrowing on this successful track record, numerous medical training team (MTT) programs have been developed and implemented in hospitals, using classroom and simulator-based programs to create and reinforce reliable, effective teamwork. Some of these programs are specific to medical specialties, such as anesthesia, whereas others are multidisciplinary. MTT is simple in concept but tricky in execution. The conceptual basis for MTT is that, overall, teams make fewer mistakes than individuals, especially when team members understand their responsibilities as well as the roles of the other team members. Creating a team structure is, of course, no guarantee that it will operate cohesively and yield the hoped-for improvements in patient safety. Nonetheless, in the right setting, MTT has proved to be a wise hedge against the perils of individual decision making in fast-changing, complex health care environments. The tricky execution involves the reality that many MTT programs are not designed to reflect the complex interactions and dynamics that occur when decisions about a patient’s condition and care requirements are completed at one level of care and then transferred to the next—whether the transition is to an inpatient bed or back to the patient’s home. These care transitions, or “handoffs,” almost always involve more than 1 physician and 1 nurse and often include medical residents, pharmacy staff, support personnel, and home care providers as well.