Lessons Learned

Complexity of Care Post-Discharge

In the quality and patient safety world, we have a tendency to focus on the complexity of patient care within the hospital setting. However, a classic study by Forster, et al1, reminds us that there are many concerns for the complexity of care post-discharge. Nearly 20 percent of patients experience adverse events within three weeks of discharge; about 75 percent of which are preventable. Adverse drug events are the most common post-discharge complication, with hospital-acquired infections and procedural complications also causing considerable morbidity. Additional hazards arise when patients are discharged with test results pending and when the discharge plans include diagnostic workups to be completed as an outpatient, placing patients at risk unless timely and thorough follow-up is ensured. In order to reduce preventable hospital readmissions within 30 days of discharge, minimizing post-discharge adverse events has become a priority.

Poorly coordinated care transitions are at the root of most adverse events arising after discharge. Lack of direct communication between inpatient and outpatient providers is common, since as traditional communication systems (such as the dictated discharge summary) generally fail to reach outpatient providers in a timely fashion and often lack essential information. Patients frequently receive new medications or have medications changed during hospitalizations, yet medication reconciliation at discharge is generally inadequate and not well communicated. This results in the potential for medication discrepancies and adverse drug events—particularly for patients with low health literacy, or those prescribed high-risk medications or complex medication regimens.

Even if communication between providers is timely and accurate, and appropriate steps are taken to ensure medication safety, patients and their families still assume a large burden of care after discharge. Accurately assessing patients’ abilities to care for themselves after discharge can be difficult and requires a coordinated multidisciplinary effort. Failure to enlist appropriate resources to help with the transition from hospital to home (or another health care setting) may leave patients vulnerable.

Improving transitions in care

Ensuring safe care transitions requires a systematic approach. Three key areas must be addressed prior to discharge:

  • Medication reconciliation: Crosscheck the patient’s medications to ensure that no chronic medications are stopped and to ensure the safety of new prescriptions. 
  • Structured discharge communication: Communicate information on medication changes, pending tests and studies, and follow-up needs accurately and promptly to outpatient physicians. 
  • Patient education: Make sure that patients (and their families) understand their diagnosis, their follow-up needs and whom to contact with questions or problems after discharge.

Resources:

Forster AJ, Murff HJ, Peterson JF, et.al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Inter Med. 2003;138:161-167.

Kripalani S, LeFevre F, Phillips CO, et.al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297:831-841.

Kripalani S, Jackson AT, Schnipper JL, Dolemena EA. J Hosp Med. 2007;2:314-323.

Medication Reconciliation. AHRQ Patient Safety Network. Located at http://psnet.ahrq.gov/primer.aspx?primerID=1

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