Safety Issues at Transitions of Care: Pain points relating to clinical systems

This report looks at transitions of care and identifies key safety issues, pain points and opportunities for improvement in clinical systems. It describes the outcomes of consultations undertaken by the Commission on behalf of the National Health Chief Information Officer (CIO) Forum.

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Report methodology

The consultations aimed to identify safety issues and pain points related to clinical information systems at transitions of care between the primary and acute care sectors. A literature review, targeted interviews and stakeholder workshops were conducted. More than 80 participants from the medical, nursing, allied health, informatics, management and health consumer sectors contributed to the project.

The report was  endorsed by jurisdictional CIOs and the Australian Health Ministers Advisory Council.

Key safety issues

The table below summarises the key safety issues that have been identified and areas for improvement.

Safety issue Areas for improvement
Poorly defined models of person-centred care
  • Define an updated model of person-centred, team-based care and communication
  • Enable an understanding about why information is being communicated between care teams and clinicians at transition points
Poorly defined responsibility and accountability for communication at transitions of care
  • Define the roles and responsibilities of the clinicians involved in transitions of care
  • Define who is accountable for the communication at transition points
Inadequate engagement of patients in care planning and communication
  • Improve the engagement of patients in both hospital and primary care settings
Limited access to complete and current health and social information
  • Improve the compatibility of electronic information systems so it is easier for clinicians to have access to patient data and communicate during transitions of care
  • Allow clinician access to patient data across different clinical information systems
  • Secure communication systems
  • Improve access to the My Health Record system
  • Allow access to a reliable national clinician database
Limited opportunities for medication reconciliation  
Inadequate discharge planning
  • Define the roles of the clinicians who are responsible for communications on discharge
  • Define who is accountable for the communications on discharge
  • Improve the compatibility of information systems, so that all relevant information is easy to access and can be included in hospital discharge planning

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