Our job in healthcare is to identify the at-risk populations we encounter, and the information, tools, and behaviors we need to mobilize to seal the cracks and effectively transfer patient information among the members of the patient's healthcare team.
If we are to promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another, we must broaden our view of the who, what, and how involved in achieving effective transitions of care.