Resources to prevent medical errors during transfer of care

Medical errors can be costly for both patient and hospital. As defined by the Joint Commission (, in order to keep patients safe, clinicians should focus on the three key points along the patient’s continuum of care. To help, free resources are available.

Upon admission
Patient admission is a critical time for risk assessment. Clinicians should employ screening tools to identify high-risk patients before procedures. For patients potentially receiving opioids, this can include the Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose (RIOSORD).

Patient recovery
As patients recover from procedures, it is common for patient-controlled analgesia (PCA) pumps to be employed to manage pain. The Physician-Patient Alliance for Health & Safety (PPAHS) PCA Safety Checklist is a free downloadable resource developed by a panel of experts to reduce the risk of opioid-related adverse events (

Patient discharge
Clinicians should take steps to actively engage patients and their families as partners in their health. Patients are encouraged to ask the following five questions about their medications: 
1.    Have any medications been added, stopped, or changed, and why?
2.    What medications do I need to keep taking, and why?
3.    How do I take my medication, and for how long?
4.    How will I know if my medication is working, and what side effects do I watch for?
5.    Do I need any tests and when do I book my next visit?

We encourage clinicians to download a PDF version of these five questions and share it with their patients (

For more resources dedicated to patient safety, visit the Canadian Patient Safety Institute (CPSI) and PPAHS websites (,
—Stephen Routledge, MPH
Patient Safety Improvement Lead
Canadian Patient Safety Institute 
—Michael Wong, JD
Founder and Executive Director 
Physician-Patient Alliance for Health and Safety

Stephen Routledge, MPH, Michael Wong, JD. Resources to prevent medical errors during transfer of care. BCMJ, Vol. 60, No. 1, January, February, 2018, Page(s) 60 - News.

Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.

An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.

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For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit

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