Hospital ICU Transfers Pose High Risk for Medical Errors, Communication Breakdowns: Study

The process of transferring patients from an intensive care unit (ICU) to a hospital ward can be challenging for medical staff and risky for the patient, but certain factors can help make the transition safer, according to the findings of a new study. 

In findings published this week in the Canadian Medical Association Journal (CMAJ), researchers identified three factors that were key to creating a safe and smooth transition for high-risk patients moving from the ICU to a hospital admission, including: resource availability, communication, and institutional culture.

According to the researchers, ICU transfers are challenging because it involves some of the most severely ill patients in the health care system. In addition to their health situation, those patients face increased risk of medical errors, adverse events, readmission, dissatisfaction with care, and death.

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Researchers interviewed four participants from each site, including one patient, one family member, one ICU staff member, and one hospital ward staff member, during transfers from intensive care units to hospital wards. The sample included participants from eight hospitals in Canada from seven different cities.

Patients and staff members called for both physical and human resources to be available during the transfer process. Staff members echoed this concern.

Finding ways to avoid communication breakdowns during transfers was especially key, according to staffers. However, family members were focused on receiving accurate information concerning the transfer in a timely manner.

With regard to institutional culture, both staff and patients said the culture of the ward and attitudes of the staff contributed to the clinical environment and a sense of vulnerability or well-being for the patient.

Some of the common recommendations researchers were given included:

  • Implementing standardized communication tools that streamline communication from staff to staff and from staff to patient.
  • Using multimodal communication to help facilitate timely, accurate, durable, and mutually reinforcing information transfer.
  • Developing procedures to manage delays during transfers to ensure continuity of care for patients in the ICU waiting for a hospital ward bed.

“Patient transfers from the ICU are complex events that can disrupt continuity of patient care, yet little is known about the experiences of key stakeholders,” the researchers wrote. “Our study provides a multicentre qualitative report of patient, family member, ICU and ward provider perspectives of why transfers…can break down, and how they can be improved to enhance quality of care and improve stakeholder experiences.”


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