Patients are especially vulnerable during care transitions. Don't let healthcare break at the seams.

By Shannon Kooker (Davila), MSN, RN, CPPS, CPHQ, CIC, FAPIC
Vice President, Clinical Excellence and Patient Safety

Healthcare is full of handoffs. Patients move from home to the hospital, from the ICU to a stepdown unit, from the hospital to a skilled nursing facility, and many other care transitions. Every one of those moves is a moment when care can break down. Things can fall through the cracks, leading to inefficiencies at best, and patient harm at worst.

Several ECRI assessments underscore this issue:

• Our deep dive into maternal care safety indicated communication and hand-off issues during patient transitions are among the top factors leading to maternal safety incidents.
• ECRI named Inadequate Communication and Coordination during Discharge one of the biggest patient safety concerns of 2025, and the problem persists.
• Transitions between long-term care facilities and emergency departments are especially complex. When done poorly, it can lead to longer hospital stays and poor health outcomes.
• ECRI analyses of discharge documentation found drastic inconsistencies in content and organization, causing confusion for patients and frustration for clinicians. That’s a red flag considering these documents are critical during care transitions.

Chronic Disease Patients

These and other studies underscore that when patients transition from setting to setting, they’re vulnerable to errors and overlooked hazards. Patients with chronic, noncommunicable diseases such as cardiovascular diseases, cancers, diabetes and chronic respiratory diseases make transitions of care often. Because these conditions are managed over decades, across numerous hospitals, clinics, pharmacies, homes and caregivers, every risk inflection point is multiplied, presenting more opportunities for delayed diagnosis, mismanaged medication, and insufficient self-care. 

Picture a patient being discharged from the hospital. He has heart failure and diabetes. Three different clinicians have prescribed him eleven medications. He has been admitted to this hospital several times in the last decade, plus visited nearby urgent care clinics along the way. Despite everyone's best intentions, he leaves with two different heart medications that do the same job, (introducing unnecessary risk without doubling the intended benefits), and no instruction on the daily weight check that would catch fluid buildup before it becomes an ER visit. The hospital hands him a folder of paperwork and a follow-up appointment card. By the time he actually reads his after-visit summary, he's too tired to review it carefully and too overwhelmed to understand it.

This problem is bigger than one patient. In many health systems, the handoff at discharge is treated as a documentation task, not a clinical one, and no single person owns it. That's often because documentation is what gets audited, while the handoff itself doesn't. The hospital staff aren’t to blame for this situation; the system’s design was flawed and it produced these outcomes accordingly.

Insufficient System Design

No one clinician owns the interval between care settings, or the downstream impact of a poorly executed transition. Most safety systems can’t detect that a patient’s condition is deteriorating across four care facilities over several months, for example. Yet that is a common scenario for patients with chronic conditions. Our nation’s entire safety apparatus – from incident reporting to root cause analysis – is built to examine distinct events inside one organization’s walls. But harm from chronic disease accumulates. It does not present as an event. As gaps between care settings have no clear owner, responsibility often defaults to the patient, which they’re not always equipped to handle.

Medication Reconciliation

Medication reconciliation lives at the seam between care settings: at admission, during inpatient care, and at discharge. When it works well, it ensures the patient’s medication list is accurate and their medications are administered properly. In practice, it can result in a transition failure with no accountable owner. Part of the reason is technical: often hospital, pharmacy, and outpatient systems can't easily talk to each other, so no single source of truth follows the patient across the transition.

We analyzed 10,000 safety events in the ECRI and ISMP PSO dataset and found 73% of medication reconciliation errors took place during care setting transitions: in admission, discharge or transfer. Behind these numbers are real patients.

• In one report, an elderly man was being discharged from the hospital when his wife asked the doctor, “should he keep taking his aspirin?” That simple question revealed six medications were missing from his admission record.
• In another case, a woman in the MICU was administered doses of an antipsychotic and an anticonvulsant before the care team discovered the medication reconciliation inaccuracies; she didn’t need those pills. 
  These are daily realities that the health systems and hospitals nationwide strive to avoid.

Interoperability Struggles

Information often moves slower than patients in these hand-offs. Poor interoperability of medical records is known to contribute to delays in care, diagnostic errors and patient harm, and our fragmented national health technology infrastructure is a clear obstacle. One unified health record that follows a patient for life – to every doctor, hospital, specialist and pharmacy – would strip out enormous uncertainty, inefficiency and errors. 

Empower Patients and Caregivers

The one constant is the patient. Their voices – and those of caregivers – are critical to keep care transitions safe. Patients must be vocal advocates for themselves to ensure all their questions are answered and their care plan is clear. Self-care is where most chronic disease management actually happens, and it is delivered by patients and family caregivers who are untrained, and sometimes unsupported. Some health systems hand a patient a folder of printouts and call it patient education, but for one reason or another, don’t confirm the patient understands it well enough to put it into action at home. Healthcare organizations need meaningful partnerships with patients living with chronic disease to identify risks and co-develop solutions. As part of AHRQ’s Making Healthcare Safer IV reports, ECRI conducted a rapid review to summarize literature on patient safety practices that engage family caregivers during care transitions, which calls for structured, system-delivered communication practices.

Resources

There isn’t a one-size-fits-all approach to transitions in care. AHRQ's Making Healthcare Safer review found the evidence for transitional care interventions mixed and varied. Explore the resources below for evidence-based insights on safe care transitions:

• Optimizing Emergency Department Care Transitions for Long-Term Care Patients
• Inadequate Communication and Coordination during Discharge
• Consequences of poor care coordination for patients with complex medical conditions
• Tools for Supporting Medication Reconciliation in Ambulatory Care
• Engaging Family Caregivers with Structured Communication for Safe Care Transitions
• Advancing Evidence-Based Safety: ECRI’s Contributions to Making Healthcare Safer IV
• Improving care transition scores on the Hospital Consumer Assessment of Healthcare Providers and Systems survey
• Optimizing Inpatient Discharge Procedures following Extended Hospital Stays
• Best practices for effectively managing practice drift by reinforcing patient safety protocols

The selected reports are ECRI member-only resources made public this World Patient Safety Day. For information about navigating other member-only resources, email ClientServices@ECRI.org. 

World Patient Safety Day (WPSD)
September 17, 2026
“Safe care for noncommunicable diseases (NCDs)”
Noncommunicable diseases are long-term conditions, such as cardiovascular diseases, cancers, diabetes and chronic respiratory diseases. NCDs are estimated to account for 74% of deaths worldwide. People living with NCDs are particularly vulnerable to preventable harm. With some conditions, such as cancer, up to 1 in 3 patients experience adverse events during care. Many people also live with multiple chronic conditions, further increasing the risk of harm. Read more from the World Health Organization