Upcoming Grand Rounds

Room: Clara Christie (HSC)

Join by Zoom: https://albertahealthservices.zoom.us/j/63868147270?pwd=YAK9NGxhbqzFETr0vWKedaNrvYr9ZS.1
Meeting ID: 638 6814 7270
Passcode: 871943

 DEM Academic Grand Rounds Evaluation Google Form

Speaker: Dr. Jayelle Friesen, MD, MSc, PGY3 Emergency Medicine, Cumming School of Medicine, University of Calgary
Moderator:   Dr. Mike Szava-Kovats, ED Physician & QAER Lead
Title:  Lost in Transition: Handover and Conditional Discharge in a Missed Hip Fracture
Description: This case-based quality review examines a missed hip fracture in the emergency department, highlighting how handover practices and conditional discharge processes intersected to create patient safety vulnerabilities. Through a systems lens, we will explore opportunities to strengthen reliability in transitions of care.
Summary/Teaching points:
- Handover is a High-Risk Clinical Moment: Incomplete synthesis, task-focused sign-out, and unclear ownership can allow diagnostic uncertainty to persist across transitions.
- Automation Changes Risk—It Doesn’t Eliminate It: Order sets, decision supports, and templated processes can introduce new failure modes when they replace, rather than support, clinical reasoning.
- Conditional Discharge Requires Explicit Safety Framing: Discharge contingent on pending results or reassessment must include clear accountability, contingency planning, and patient communication.