As one of the nation's first and most trusted Patient Safety Organizations, we understand the importance of knowledge sharing in order to improve the quality of healthcare. For this reason, Clarity PSO publishes a series of educational reports--The Clarity PSO Learning Series--that focus on the risk-quality-safety (RQS) issues we have spotted through our incident reporting data collection and analyses. These reports include our findings on a given topic and our recommendations on how to use knowledge to mitigate risk and improve patient safety.
It is well-known that during transitions of care, whether they be within a department, across an organization, or external (transfer or discharges), those moments of transition and a good/safe handoff are essential due to the extensive vulnerability for errors that may occur when a patient moves through the healthcare system. This latest report explores such patient transfers and the causes of delays in medication therapy.