Transitions of care—when patients move across care sites within the health system—pose both an opportunity and a threat to patient welfare.1 These transitions are an opportunity because they provide a chance to freshly reevaluate the patient's medical needs in a new clinical setting. In the case of hospital admission, transitions also offer an opportunity to leverage an acute illness to increase healthy behaviors. To borrow a term from medical education, they are a “teachable moment” in which the threat of a medical illness may facilitate lifestyle changes, medication adherence, or other healthy actions on the part of the patient. However, transitions of care are also a threat, especially for patients with chronic diseases and complex treatment regimens. Either because of miscommunication or simple error, patients may experience unwarranted changes in treatment with potentially deleterious effects on their health.2,3
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