Transitions in healthcare often go unnoticed—until they don’t work. Whether a patient is moving from the emergency room (ER) to the ICU, from surgery to recovery, or from hospital to home, every shift brings risks and opportunities. These are moments where the healthcare system can either support recovery or let vital details fall through the cracks.

As a nurse, I’ve watched these transitions unfold in real time. I’ve seen how personal belongings like glasses, hearing aids, and cell phones disappear. I’ve seen families left in the dark, not knowing where their loved ones are—or what comes next. I’ve seen the ripple effects of rushed handoffs, incomplete communication, and systems stretched to the limit.

This first post in a three-part series takes a closer look at hospital transitions: what they are, where they break down, and how we can do better—for patients, families, and the teams who care for them.

 

What Is a Transition of Care?

A care transition isn’t just a physical move from one room to another. It’s a critical period where clinical decisions, patient safety, and communication all intersect. It might be:

• Moving from the ER to the ICU
• Being transferred to a surgical floor
• Going from inpatient care to a skilled nursing facility
• Discharging from hospital to home

Each of these transitions includes a chain of handoffs—between providers, departments, systems, and families. And each one has the potential for dropped information, delayed care, or lost trust.

 

How Many Moves Does a Typical Patient Experience?

When considering movement from the ER through to discharge, the number of moves varies by hospital layout, patient condition, and care needs.

• 59.4% of patients are not moved after their first placement
• 27.6% are moved once
• 8.1% are moved twice
• 4.9% are moved three or more times

 

The path might look like this:

1. ER to initial ward or observation unit
2. Within-ward moves (due to bed availability or need for closer monitoring)
3. Between-ward transfers (for specialized care like ICU or surgical units)
4. Discharge (from final ward or discharge area)

 

Every move creates a new opportunity for delays, miscommunication, or missed care.

 

What Really Happens During Transitions

Imagine being admitted to the ER with abdominal pain. It turns out to be gallstones, and you’ll need surgery. At this point:

• Your belongings are bagged and labeled.
• Your care is handed off from the ER team to the surgical team.
• Notes are entered into the electronic health record (EHR)—hopefully with accuracy and clarity.
• Orders for tests, medications, or monitoring are sent along.

In theory, it’s a smooth process. But in reality? Rooms are full, staff are stretched thin, and the ER doctor might communicate with the next team in passing or through a rushed note. Your glasses might get left behind. Your family may not know where you’ve gone or when they can see you. And you may be too overwhelmed to ask questions.

 

Why the System Matters

Transitions of care are not just clinical formalities—they’re pivotal moments with serious consequences. When the system fails during a handoff, the ripple effects can be dangerous and costly.

 

The Cost of Poor Transitions

• Nearly 1 in 5 Medicare patients is readmitted within 30 days (AHRQ).
• $26 billion in readmission costs hit the U.S. healthcare system annually, with $17 billion considered avoidable (CMS).
• Almost 50% of serious post-discharge adverse events are due to medication errors—often from poor reconciliation at discharge (J Gen Intern Med).

 

 The Risk to Patient Safety

• 20% of patients experience an adverse event within three weeks of discharge; two-thirds of those are medication-related (NEJM).
• The Joint Commission lists care transitions among the top five causes of sentinel events (preventable harm or death).

 

What Patients and Families Can Do

• Ask for written discharge instructions and medication lists.
• Request that belongings be tracked and documented.
• If English isn’t your first language, request an interpreter.
• If caring for someone with dementia, advocate persistently.

The ER is often chaotic, and your voice is a vital safety tool.

 

 Coming Up Next: Part 2 — What Falls Through the Cracks: Lost items, lost records, and lost patients.