What Are the Biggest Issues Relating to Transferring? Addressing Risks in Healthcare

October 1, 2025 •

5 min read

According to a study, 80% of serious medical errors are attributed to miscommunication during patient transfers. Understanding what are the biggest issues relating to transferring patients is crucial for safeguarding patient health and ensuring a seamless transition across different care settings.

Quick Summary

The process of transferring patients in healthcare is fraught with potential risks, including communication failures, incomplete records, and logistical hurdles. Addressing these challenges is vital for maintaining continuity of care, preventing medical errors, and reducing stress for patients and their families during critical transitions.

Key Points

Communication Failure: Flawed handoffs are a leading cause of medical errors during patient transfers, often due to fragmented communication methods and a lack of standardized protocols.
Medical Record Gaps: Missing or inaccurate medical records, sometimes worsened by poor interoperability between different EHR systems or improper use of copy-pasting functions, can lead to diagnostic and treatment errors.
Continuity of Care Disruption: Without clear coordination and shared care plans, there can be significant gaps or lapses in medical attention, which negatively impact patient outcomes.
Patient Safety Incidents: Transfers carry inherent risks such as falls, equipment malfunctions, and medication errors, requiring meticulous planning and safety checks.
Emotional and Financial Strain: Navigating complex transfers is often stressful for patients and their families, with added anxieties over insurance coverage and unexpected costs.
Insufficient Patient Education: Inadequate information provided to patients and families about their new care plan can lead to confusion and errors in at-home care.
Logistical Hurdles: Coordinating transport, ensuring all necessary medical equipment is available, and managing timing can pose significant logistical challenges.

Patient transfers, whether between hospital units, facilities, or from a hospital to home care, represent a vulnerable period in a patient's care journey. For a process that occurs millions of times annually, the risks involved are significant and can lead to adverse events, increased costs, and poor outcomes. The biggest issues relating to transferring often arise from system-wide failures that undermine the transfer of critical information and care.

Communication Failures and Flawed Handoffs

Communication breakdowns are consistently cited as the leading cause of problems during patient handoffs. A patient's care information is typically transferred from one provider or team to another through a verbal or written report. However, fragmented and inconsistent communication methods create ample opportunity for vital details to be lost or misinterpreted.

The Dangers of Incomplete Information

Without a standardized, clear, and concise handoff procedure, clinicians may fail to convey crucial information about a patient's status, pending test results, or anticipated problems. Relying on fragmented methods like pagers, faxes, or verbal reports in a noisy environment can lead to significant delays and misunderstandings. The consequences can be severe, ranging from delayed diagnosis to fatal medical errors.

Lack of Standardization: When every team or department uses a different method for handoffs, inconsistencies are inevitable. Standardized protocols, such as SBAR (Situation, Background, Assessment, Recommendation), can ensure all essential information is consistently communicated.
Distractions and Interruptions: Handoffs that occur in busy or chaotic environments are highly susceptible to errors. Patient safety is compromised when care providers are distracted and unable to focus completely on the information being exchanged.

Inaccurate and Incomplete Medical Records

Medical records are the backbone of patient care, but transferring them effectively is a major challenge. Gaps in patient medical histories are common during transitions and can lead to inappropriate interventions or missed treatments.

Challenges with Electronic Medical Records (EMRs)

While EMRs were designed to improve information flow, they introduce their own set of problems during transfers.

Interoperability Issues: Different healthcare systems often use different EMR platforms that do not communicate with each other seamlessly. This lack of interoperability can leave receiving facilities without a complete and accurate picture of the patient's history.
Copy-Pasting Errors: The convenience of copy-pasting previous notes into a new record can cause outdated or inaccurate information to be propagated, creating discordant and misleading records.
Data Overload: EMRs can sometimes contain an overwhelming amount of information, making it difficult for a receiving provider to quickly find the most essential clinical details.

Logistics and Coordination Hurdles

The physical and logistical aspects of transferring a patient add another layer of complexity. Poor coordination can lead to delays, logistical errors, and increased stress for everyone involved.

Inter-facility vs. Intra-facility Transfers

Whether a patient is moving from one floor to another or being transferred to a different hospital entirely, coordination is key. Inter-hospital transfers are particularly challenging due to the need for cooperation between different organizations, including ensuring transfer agreements and securing appropriate transportation.

Logistical Challenges Include:

Transportation: Securing appropriate medical transport, such as an ambulance equipped for complex patient needs, must be coordinated in advance to prevent delays.
Specialized Equipment: For patients with complex medical needs, specialized equipment like ventilators or feeding tubes must be moved and set up correctly at the new location.
Staffing: Ensuring adequate and skilled staff are available for the transport and at the receiving location is crucial for safety and continuity of care.

Patient Safety Risks

Patient transfer is not just an administrative process; it carries inherent safety risks that must be managed proactively.

Falls: Patients, especially those with weakness or altered mental status, are at a higher risk of falls during transfers between beds, stretchers, and wheelchairs.
Medication Errors: Roughly 60% of medication errors occur during care transitions. Failures in medication reconciliation—the process of comparing a patient's home medications to new ones—are a significant risk factor.
Equipment Malfunctions: Critical equipment used during transport can malfunction, interrupting crucial treatments.

Emotional Stress on Patients and Families

Beyond the clinical risks, the emotional and psychological toll on patients and their families is a major issue.

Anxiety and Confusion: Leaving a familiar care setting and adjusting to new routines and caregivers can be highly stressful.
Lack of Information: Patients and their families are often inadequately informed about the transfer process, leading to confusion and heightened anxiety. Engaging patients in decision-making can help reduce this stress.
Insurance and Financial Concerns: Navigating insurance coverage for a new provider or facility can be a significant obstacle and source of stress.

How to Mitigate Transfer Issues

Addressing these challenges requires a multi-faceted approach involving clear communication, standardized protocols, and patient engagement.


Comparison of Transfer Processes	Feature	Effective Transfer	Poor Transfer
Communication	Standardized, interactive communication protocols (e.g., SBAR, I-PASS)	Fragmented communication, reliance on voicemails or faxes
Medical Records	Access to a comprehensive, accurate electronic health record (EHR)	Medical record gaps, propagation of outdated info via copy-pasting
Coordination	Pre-planned logistics, designated care coordinators, and clear transfer agreements	Delayed transport, equipment issues, and unclear roles
Patient Involvement	Involves patients and families in decisions, provides thorough education	Excludes patients and caregivers from the planning process
Safety Measures	Checklists, adequate staffing, and proper equipment	Hurried handoffs, improper patient lifting techniques, lack of equipment

Conclusion

While the healthcare system has made strides in improving patient care, the process of transferring remains a critical area with significant risks. By addressing the biggest issues relating to transferring—including communication breakdowns, medical record inaccuracies, logistical difficulties, and psychological stress—healthcare providers can enhance safety and ensure better continuity of care. Standardized procedures, robust use of technology, and active engagement with patients and families are essential to minimizing these risks and improving patient outcomes during transitions. For more insights on this topic, the Agency for Healthcare Research and Quality (AHRQ) offers valuable resources and tools for improving patient safety during transitions of care.

What are the biggest issues relating to transferring? A summary

Poor Communication: Handover breakdowns and incomplete information exchanges between care teams are major risks.
Incomplete Medical Records: Gaps in patient history or medication lists often occur, leading to potential errors.
Logistical Challenges: Arranging safe and timely transportation, along with necessary medical equipment, can be difficult.
Patient and Family Stress: Transitions are emotionally taxing for patients and caregivers, exacerbated by a lack of communication.
Medication Errors: Medication reconciliation failures are common during transfers, representing a serious patient safety risk.

Frequently Asked Questions

The most common issue during patient transfers is communication failure. Incomplete or hurried handoffs of information between healthcare providers, whether through verbal reports, faxes, or EMRs, frequently lead to medical errors and compromised patient safety.

While intended to help, EMRs can cause issues during transfers due to a lack of interoperability between different systems, which prevents seamless data exchange. Additionally, the practice of copy-pasting old information can lead to the spread of inaccurate data.

Significant patient safety risks include medication errors, falls during the physical move, interruptions in critical treatments, and adverse events related to incomplete handoffs. Transferred patients often experience worse outcomes overall.

For many patients and their families, transferring is a stressful and confusing process. Leaving a familiar environment, adjusting to new routines, and uncertainty about their new care can heighten anxiety and emotional distress.

Logistical challenges, such as delays in securing appropriate transportation or ensuring that specialized medical equipment is ready at the new location, can stall the transfer process and lead to gaps in care.

Medication reconciliation is the process of reviewing and comparing a patient's medication list at transition points. It is crucial for ensuring accuracy, as about 60% of medication errors occur during transitions, and failures can lead to adverse drug events.

Proper education of patients and caregivers is vital for a safe transition, especially to a home care setting. Inadequate information about new medications or equipment can lead to errors, while involvement in the process can reduce stress and increase compliance.