• Stephen Harden

How To Fix Patient Transfer Errors

47 percent of patients lost a diagnosis when transferring between hospitals, according to a recent study.


Data from more than 180,000 patients, 18 years or older, in 5 states over a three-year period was studied by the University of Minnesota Medical School. Researchers also found that 73 percent of patients gained a new diagnosis following transfer.


It's really difficult to get great care when you add, or lose, a diagnosis just from being transferred between facilities.


Here are 6 ways to fix patient transfer errors to improve patient safety:


1. Participate in a data sharing mechanism such as a health information exchange. Participation is associated with a lower rate of information loss and lower mortality.


2. Create a standard protocol for transferring patients. Every caregiver must transfer every patient the same way, every time.


3. Make the transfer protocol mandatory. Research shows that processes that are clearly labeled "mandatory" get a much higher rate of compliance.


4. Provide training on the use of the transfer protocol. Training must include:

  • Information on how to do it, and why to do it

  • A demonstration of how to correctly use the transfer protocol (e.g. modeling the behavior)

  • An opportunity to practice the protocol under the watchful eye of a coach

  • Feedback on how well the practice met the model


5. Ensure the transfer protocol requires a read-back. Whether the read-back is verbal or written, unless the sending facility gets a confirmation from the receiving facility, you don't really know if the patient information was transferred correctly.


6. Track the metrics on transfer accuracy. Collect and transparently share to all staff involved in transferring patients the data on transfer accuracy. Create a dashboard and ensure it is widely available.


If you'd like coaching on how to do this, sign up for a free consultation here.


Healthcare quality will never show systematic improvement if we can't fix these basic issues.



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