Table 2

Measures identified categorised according to the KCoIToC processes and mapped according to SEIPS, their timing and the potential for real-time use

KCoIToC component	Measures associated with KCoIToC components (SEIPS work system elements involved (people, tasks, tools, environments))	SEIPS framework measured/timing (lagging, leading, real time)	Potential for real time using digital health systems
Discharge planning	Enrolment into clinic/outpatient appointment made60 84 87 Tasks: booking appointment, documenting appointment	Work system/leading	Documentation and alert.*
	Access obtained for home injections of high-risk medication87 People: patient, staff Task: performing cannulation Tool: cannulation equipment	Outcome/lagging	Documentation and alert.
	Medication availability confirmed76 87 People: patient and/or carer, staff Task: determining medication availability Tools: medication, telephone, computer	Process/leading	Documentation and alert.
	Percentage of inadequate warfarin follow-up arrangements63 People: patient and healthcare professional Tasks: identify follow-up requirements, arrange follow-up Tools: digital health system, telephone, computer, diary	Process/lagging	†
Complete communication of information	Documented inpatient-to-outpatient provider contact60 People: healthcare professionals Task: documentation Tool: form of communication (paper or electronic)	Process/lagging	Documentation and alert.
	Documented inpatient-to-anticoagulation clinic communication60 People: healthcare professionals Task: documentation Tool: form of communication (paper or electronic)	Process/lagging	Documentation and alert.
	Information in discharge letter70 80 82 87 People: healthcare professionals Task: documentation Tool: form of communication (paper or electronic)	Process/lagging	Documentation and alert.
Availability, timeliness, clarity and organisation of information	Baseline laboratory information available87 People: patient, staff, laboratory staff Tasks: request, take, analyse and report blood test Tools: blood test result (electronic or paper report), patient record	Process/lagging	Alert if baseline blood test results are not available when prescription written.
Medication safety	Adverse events (hypoglycaemia or hyperglycaemia, venous thromboembolism, readmissions, death, cardiovascular events)49 57–62 64–66 69 70 72–80 82–84 86–88	Outcome/lagging	Some, for example, abnormal blood tests.
	Medications managed according to protocol71 72 74 87 People: patient, prescriber, pharmacy Task: prescribing Tools: medication, prescription, protocol	Process/lagging	†
	Medication discrepancies, errors or issues identified63 69 75 76 80–83 85 87 People: patient, prescriber, healthcare professional reviewing medications Task: medication review Tools: medications, references (eg, medication information leaflets, reference books)	Process/lagging and real time	Documentation with targeted alert to prompt review.
	Rate of recommendations agreed63 75 People: patient, staff (recommendation maker and prescriber) Tasks: prescribing, documentation	Process/lagging	†
	Medication safety recommendations made71 75 People: patient, staff (recommendation maker and prescriber) Tasks: prescribing, documentation	Process/lagging	Documentation and alert.
	Impact of interventions to optimise medications48 68 81	Outcome/lagging	†
Educating patients to promote self-management	Measures of adherence64 69 72 74 84 86 People: patient (and caregiver) Task: taking medication Tools: medication, packaging, compliance aids (eg, tablet cutters)	Process/leading	Through patient-owned digital method, for example, access to their electronic health record or smartphone application.
	Patient satisfaction56 64 69 72 77 83	Outcome/lagging for patient Leading for organisation
	Provision of education and counselling71 82 87 People: patient, healthcare professional Task: providing education Tools: information leaflets, medication charts	Process/leading	Partially—tasks (eg, education) can be documented and highlighted if outstanding.
	Assessment of patient knowledge, understanding and beliefs56 72 78 81 84 People: patient, assessor Task: assessment of knowledge Tool: assessment template/quiz	Process/leading	†
Enlisting social and community supports
Advance care planning
Coordinating care among team members	Percentage of patients with pharmacist coordination documented59 People: patient, pharmacist, multidisciplinary team Tasks: ‘co-ordination’ tasks, documentation Tool: patient records	Process/lagging	Documentation and alert.
	Pharmacist time per patient59 87	Outcome/lagging	†
	Cost of intervention88	Outcome/lagging	†
	Clinician satisfaction67	Outcome/lagging	†
Monitoring and managing symptoms after transfer	Time in therapeutic range49 57 61 65 66 70 73 77 78 83 86	Outcome/lagging and real time	Viewed within patient record.
	Time outside therapeutic range78	Outcome/lagging	†
	Time to reach therapeutic range67 73	Outcome/lagging	†
	Therapeutic drug monitoring performed87 People: patient, staff, laboratory staff Tasks: request, take, analyse, report blood test Tools: blood test equipment, laboratory equipment to analyse, blood test result (electronic or paper report)	Process/lagging	Documentation and alert.
	Percentage of international normalised ratio taken within 10 days of transfer of care67 People: patient, staff, laboratory staff Tasks: request, take, analyse, report blood test Tools: blood test equipment, laboratory equipment to analyse, blood test result (electronic or paper report)	Process/lagging	Documentation and alert.
Outpatient follow-up	Clinic appointment attendance64 66 67 People: patient, staff Tasks: book, communicate and attend appointment	Process/lagging	Documentation and alert.
Outpatient follow-up	Time to follow-up60 64 71 83	Outcome/lagging	†

*Documentation of a specific task with an associated alert targeted to relevant staff prompting action if that task remains outstanding.
†Not applicable.
KCoIToC, Key Components of an Ideal Transfer of Care; SEIPS, Systems Engineering Initiative for Patient Safety.