Case Reflection: Improving Patient Transfer in Healthcare Systems

This case study reflects on the critical issue of patient transfers between different healthcare settings, highlighting a specific instance involving a dementia patient with Diabetic Ketoacidosis (DKA). The case reveals a breakdown in communication between care homes and general practitioners, leading to medication errors and potential harm to the patient. The investigation uncovers lapses in medication records, lack of proper handovers, and inadequate follow-up by healthcare providers. The reflection emphasizes the importance of standardized transfer procedures, clear communication channels, and adherence to guidelines provided by organizations like the National Institute for Health and Care Excellence (NICE). It also underscores the role of community pharmacists in ensuring medication safety and continuity of care during patient transfers. The author advocates for compulsory sharing of essential patient information during transfers and reflects on personal responsibility as a practitioner in ensuring safe and effective transitions.

Running Head: HEALTH CARE SYSTEMS
Health care systems
June 25
2018
Case
reflection

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Patients with longer treatments are sometimes required to be transferred from one health care
unit to another. Sometimes even to the different sectors like from health care unit to care
taking home also. Such transfer of patients between different health-care sectors need to
carried with an effective management of the transfer procedures. As general practitioner I
have observed many cases in which patients are transferred to my unit very causally or with
no responsibility1. In such cases I have faced many difficulties while taking care of those
patients. In United Kingdom there is a provision of different policies or regulation to be
followed by every health care-taker in different sector of the hospitality industry. Specially in
case of older homeless people extra care has to be taken while transferring them form one
health care unit to another one as they have no families to look after them while their transfer.
In such cases general practitioners are the only responsible persons to take care of their
transfer. In United Kingdom continuity of patient-care at the time of their transfer from one
health care unit or sector to another one is national priority. Nation has shown its concern for
such issues in health-care sector and a number of interventions have been designed, and
tested to improve the safety and quality of such health-care transfers of patients. Different
activities are incorporated in many of the successful interventions like medication
reconciliation, discharge planning, proper discharge summaries, electronic notification of
discharge, web-based access to the information related to the discharge operations, and many
more similar to these2.
In recent time while practicing my general practices I came across this case in which a
dementia patient was admitted in the hospital I work in and presented to me with Diabetic
Ketoacidosis (DKA) symptoms. Dementia is referred as an overall nomination that describes
a group of symptoms which are associated with a consistent decline in the memory of patient.
In this case I came to know that the patient is transferred from a care home and the medical
administration record (MAR) chart which was sent to the hospital from the care home did not

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include any insulin in the description provided in the chart. In the treatment of DKA insulin is
of the most essential concern for any practitioner and the MAR presented to me was
indicating no insulin in the medial administration report. DKA is a potential fatal
hyperglycemic crisis that generally occurs in diabetic patients of both the stages 1 and 2. Still
diabetic patients in stage 1 are more likely to suffer from this problem3. As a practitioner I
know that DKA causes due to insufficient production of insulin in the body. Therefore,
insulin is one of the most preferred provisions to such patients and MAR chart missing the
insulin shocked me. This shows a carelessness of the care home while taking care of the
patient. Also while comparing the summary care record presented by her GP and the Mar
presented to me, I realised that insulin was the essential or indeed part of her medication.
However, none of the medication issued by her GP including any form of insulin. In order to
know the exact situation of patient I needed to investigate the case more and in the
investigation I got to know that the patient was recently transferred from one another care
home to the last one just before 3 days, and now she is getting transferred in our hospital.
During this transfer GP for the treatment was also changed but the health care report of the
patient including her medication and routine check-up reports were electronically transferred
to the new practitioner. But still new GP did not issue any of the previous medication by
assuming that the patient has had the enough dose of it. While investigating this transfer I
came to know one more shocking finding that the new GP haven’t seen the patient since she
moved into this new care home. Another finding of this investigation shows that the previous
GP had sent a copy of patient’s MAR chart and her medication to the last care home. This
MAR didn’t include any insulin and thus no insulin was sent to the new house. This incident
demonstrates a lack of communication between two care homes while transferring a patient
from one to another. This makes the staff members of new care home unaware for the fact
that the patient is diabetic and they didn’t even inquire for the insulin.

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This incident made me to realise the importance of various incorporate activities need to be
followed while transferring a patient from one care unit to another one. In this context I get to
identify some serious issues while making a transfer of a patient. I realised that a proper
procedure must be followed strictly while making such transfers and communication is the
key issue in this type of transfers. A proper communication channel has to be followed and
required information related to the patient and the treatment has to be passed from one care
unit to the other one while transferring the patient. In such cases the miscommunication may
lead to the wrong treatment and can cause potential harm to the patient’s health. To overcome
these problems must be a provision of some standards to be followed by the practitioners
while making such transfers of patients.
All my finding in this having the common issues of miscommunication suggest that the
communication system of health care units or sector while discharging a patient has to be
reviewed and must be renewed effectively. In 2012 and 2013 a report of NHS states that
around 10,000 people reported to the National Reporting and Learning System (NRLS) of
patient safety incidents that were related to the discharge operations of different health care
units. This process of discharging a patient from secondary to primary, social or community
care home is much complicated and multifactorial. In 33% cases of the 10000 reports it is
observed that the communication is an area of risk3.
During transfer of a patient general practitioners as well as the local pharmacists play an
important role in a safe transfer of the patient. These local community pharmacists can offer
an expertise in therapeutics, accessibility, drug problem related skills, and face-to-face
contact4. In a recent report issued by the Royal Pharmaceutical Society (RPS) stats that
keeping patients safe while transferring them from one care to another, right information
about the medicines and proper guidance on the treatment information should be transferred
along with the patient5.

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Today there are different interventions to take care of patient transfer. One of these
interventions includes electronic transmission of information related to the treatment of
patient. In this intervention the information related to the medication of patient is transmitted
to the new care home and the general practitioner in new care home. Community pharmacists
provide a follow-up consultation to the new GP tailored to the needs of individual patient. In
such interventions hospital staff members use an IT platform to make a better coordination of
care while discharging the patient. In a study it is stated that community pharmacists contact
most of the patients and as a result of this direct contact of community pharmacists help
patients to avoid readmission and staying in hospital for a shorter time period. To establish an
effective communication while transferring a patient there are some guidelines provided by
National institute for Health and Care Excellence6. According to these guidelines, there are
few things to be keep in mind to make an effective communication while discharging a
patient from a health care unite regardless its type of unit like hospital, social care, and
community care7. This guideline suggests including, but not limited to, following details
while transferring, contact of patient and their general practitioner, other persons identified by
the patient, nominated community pharmacy, information about known drug allergies,
reaction to different medicines and type or reactions. In the MAR sheet a clear list of the
medicines patient taking currently as well as newly prescribed medicines must be provided8.
This list of medicines should include name, form, strength, timing, dose frequency and
duration, and procedure of what and how the medicines are to be taken. Along with this
information, the communication must also include the time and duration of the last dose with
the information about last information shared with the family members or carers9.
This particular case made me to find out what information is needed to be compulsory to
share at the time of discharging a patient and I did share all the information related to the
patient as well as her treatment progress in while she stayed in the hospital under my

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supervision. GP should personally handover all the information to her family members and
also shared the same information with her new GP and care taker at the time she was
discharging from the hospital10. While sharing this information I got a satisfactory feeling
about my responsibility as a practitioner. Being a practitioner GP should recommend that it
should be made compulsory ton provide the essential information related to the patient and
their treatment while transferring them from one care unit to another11. This experience made
me identify some key information that should be shared by the GP at the time or discharging
their patient. Similar to this case while discharging her GP should share details of medication
changes with care home, local chemist, and new GP, a clear discharge summary including
both new and existing medication details, new MAR chart providing clear instruction for
regular medications, and also discussed and highlighted the diabetic problem, type of insulin
to be provided along with its management to the care home where she was going to be
transferred from this hospital12.
In the end I would conclude that the case made to understand the importance health care
interventions and the information essential to share with the patient or new GP while
discharging a patient. While investigating and understanding the problem and its alternative I
got to know about different initiatives taken by the NIHCE to make a safe transfer of patient
especially older homeless patients.

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References
1. Etters L, Goodall D, Harrison BE. Caregiver burden among dementia patient
caregivers: a review of the literature. Journal of the American Association of Nurse
Practitioners. 2008 Aug 1;20(8):423-8.
2. Graff MJ, Adang EM, Vernooij-Dassen MJ, Dekker J, Jönsson L, Thijssen M,
Hoefnagels WH, Rikkert MG. Community occupational therapy for older patients
with dementia and their care givers: cost effectiveness study. Bmj. 2008 Jan
17;336(7636):134-8.
3. NHS England. Patient Safety Alert. 2014 August 29 [cited 2018 June 24]. Available
from: https://www.england.nhs.uk/wp-content/uploads/2014/08/psa-imp-saf-of-
discharge.pdf
4. Brady MC, Stott DJ, Norrie J, Chalmers C, St George B, Sweeney PM, Langhorne P.
Developing and evaluating the implementation of a complex intervention: using
mixed methods to inform the design of a randomised controlled trial of an oral
healthcare intervention after stroke. Trials. 2011 Dec;12(1):168.
5. Royal Pharmaceutical Society. Keeping patients safe when they transfer between care
providers. 2016 October 6 [cited 2018 June 24]. Available from:
https://www.rpharms.com/resources/quick-reference-guides/keeping-patients-safe
6. Nazar H., Brice S., Akhter N., Kasin A., Gunning A., Slight S. P., and Watson N. W.
New transfer of care initiative of electronic referral from hospital to community
pharmacy in England: a formative service evaluation. BMJ open 2016; 6; 1-9.
7. NICE Transition between inpatient hospital settings and community or care home
settings for adults with social care needs. 2015 December. [cited 2018 June 24].
Available from: https://www.nice.org.uk/guidance/ng27

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8. Nationaal Institute of Health and Care Excellence. Medicines optimisation overview.
2015 [cited 2018 June 24]. Available from:
https://pathways.nice.org.uk/pathways/medicines-optimisation#content=view-node
%3Anodes-communication-during-transfer-of-care
9. Fuller C, Michie S, Savage J, McAteer J, Besser S, Charlett A, Hayward A, Cookson
BD, Cooper BS, Duckworth G, Jeanes A. The Feedback Intervention Trial (FIT)—
improving hand-hygiene compliance in UK healthcare workers: a stepped wedge
cluster randomised controlled trial. PloS one. 2012 Oct 23;7(10):e41617.
10. Health & Social Care Joint Unit and Change Agents Team. Discharge from hospital:
pathway, process and practice. 2003 January 28 [cited 2018 June 24]. Available from:
http://webarchive.nationalarchives.gov.uk/20130104194213/http://www.dh.gov.uk/
en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_4003252
11. Department of Health and Social Care. National Service Framework: older people.
2001 March 10 [cited 2018 June 24]. Available from:
https://www.gov.uk/government/publications/quality-standards-for-care-services-for-
older-people
12. Mahmud N, Rodriguez J, Nesbit J. A text message-based intervention to bridge the
healthcare communication gap in the rural developing world. Technology and Health
Care. 2010 Jan 1;18(2):137-44.