Transitions in care, from hospital to home, ward to ward, or mental health units to community settings, represent one of the most vulnerable points in the patient journey. They are often where harm hides, communication falters, and accountability blurs. Despite years of reports, policy guidance, and improvement initiatives, the same themes keep reappearing in our incident reviews.
So we must ask: are we truly learning from these events, or merely reporting them? Common risk points include hospital to community transitions for older and mental health patients, ward-to-ward transfers with limited communication, and digital system mismatches where important information does not follow the patient.
The article examines why the same transition risks persist despite the tools to prevent them being well established, from SBAR and discharge coordinators to shared digital records. It identifies the deeper causes: staff turnover eroding institutional memory, blame culture discouraging open reflection, and tick-box improvement efforts that lose momentum before embedding change.
Themes Covered
- Where patient harm during transitions is most likely to occur
- Why existing tools and frameworks are not being consistently applied
- The global dimensions of transition risk in high and low-resource settings
- How to shift from reactive reporting to a genuine learning culture
Read the Full Article on LinkedIn
The complete piece includes specific transition risk patterns, global comparisons, and practical actions for organisations committed to turning lessons identified into lessons learned.
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