International Journal for Quality in Health Care 15:441 (2003)
© 2003 International Society for Quality in Health Care
Every defect is a treasure |
Lack of clear channels of communication in patient transfer between care facilities leads to fragmentation in care
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A potential health problem in a 1-day-old infant transferred for further evaluation from a community hospital to an acute care setting is exacerbated as a result of poor communication between providers at the two facilities.
A 1-day-old infant is transferred from a community hospital to an acute care hospital to rule out a gastrointestinal bleed. An intravenous line (IV) containing calcium gluconate is infusing in his right foot. At the acute care hospital, the notes written over a 2-day
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