Why are transitions of care considered high risk?

• A. Communication breakdown leads to error and readmissions
• B. Inadequate staffing
• C. Too many specialists involved
• D. Lack of patient consent processes

Answer: (A)

In transitions of care, the main risk is communication breakdown during handoffs. When a patient moves from one setting or team to another, crucial details about diagnoses, treatment plans, medications, allergies, and follow-up needs must be transmitted clearly and received and understood by the next team. If this exchange fails, errors can occur, such as unresolved medication issues, missed follow-up appointments, or instructions that the patient and family don’t understand, all of which can lead to adverse events and even hospital readmissions. While factors like staffing levels or the involvement of many specialists can add complexity, they don’t capture the core mechanism of risk in these moments—the disruption of reliable information transfer.