Entangled in complexity: an ethnographic study of organizational adaptability and safe care transitions for patients with complex care needs.
Transitions of care are a vulnerable time for all patients and especially older adults with complex care needs. Utilizing document review, observations, and interviews, this study describes how inconsistencies in timing and precision at the time of transition put patients at risk. Examples include early discharge from hospital due to crowding, insufficient assessment of activities of daily living, and incomplete transfer of information. A safe care transition pathway describes critical steps to ensure safe transitions.