Marilyn and Kirsten know first-hand the importance of healthcare providers sharing information.
That's why Marilyn, a caregiver, and Kirsten, a UHN patient, are members of the UHN Transfer of Information (TOI) steering committee, working to improve the process among care providers.
Communication is an essential part of care, and TOI is crucial to ensure safe and efficient transfers and handovers. It is also a Required Organizational Practice (ROP) as defined by Accreditation Canada, meaning it is an essential practice healthcare organizations must have in place to enhance patient safety and minimize risk.
In addition to safety, TOI has a significant impact on patient experience.
Marilyn shared an experience as a caregiver when she accompanied a patient on a transfer between two UHN facilities on a Friday afternoon. Upon arrival at the receiving facility, staff was unaware the patient was coming and there was not a space for them. In addition, the patient's medication, scheduled for 6:00 pm, was not ready, the Pharmacy was closed, and she had to find food and blankets for her loved one.
"I felt shocked, concerned, surprised and annoyed that important information was not there to help with their care," Marilyn says. "I also felt sorry for the staff who were caught off guard and then had to scramble, and the impact that may have had on them and other patients."
The experience not only was stressful for Marilyn and her loved one, but also eroded trust. If proper TOI had been exchanged between sites, things would have been much different.
"I would have felt much more confident in the care and safety of the patient," Marilyn says.
Serious safety event narrowly avoided
Kirsten is a UHN patient and has also experienced how a lack of communication impacts care.
When she was an inpatient, Kirsten once had a nurse come to give medication intravenously. When Kirsten asked what the medication was, she realized it was something she'd never had before.
Kirsten raised a concern it might be incorrect. The nurse said the medication was correct. But when Kirsten insisted the medication be checked again, it was, indeed, found to be the incorrect one.
The medication that was about to be administered was something to which Kirsten was allergic. If she had not been aware enough to advocate for herself, the result could have been a serious safety event.
"I was worried and in shock," Kirsten recalls. "I thought this should have been flagged on my chart and wondered why is it being given to me. "I felt unsure and confused. I didn't know who else to turn to, but at the same time I knew what I was allergic to and I knew I had to be persistent (to not receive it.)
Not all patients are able to advocate like Kirsten and Marilyn, which is why it's important all members of TeamUHN have the tools and processes in place to support effective TOI.
In September, I-PASS is being introduced as the standard for information transfer at UHN. With I-PASS, situations such as the ones experienced by Marilyn and Kirsten can be avoided.
Everyone has a role to play in effective information transfer.
