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TopPatient Safety And Hospital Discharge
The Institute of Medicine (now the National Academy of Medicine) released To Err Is Human: Building a Safer Health System (Kohn et al., 2000), as a seminal call to prioritize patient safety in November 1999. This report catalyzed care-delivery and policy improvement agendas. With leadership from the Agency for Health Quality and Research, the patient care transition from the hospital to home rapidly became a priority.
Researchers subsequently reported a plethora of patient safety issues including challenges in consistently providing patients with information about their medicines, appointments, diagnoses and contingency plans if a problem arises. Such lapses result in patients correctly stating only about half of the instructions they receive (Makaryus & Friedman, 2005; Trivedi et al., 2023). Further, there are care gaps in monitoring pending tests (Moore et al., 2007) and coordinating post-discharge tests (Kripalani et al., 2007). Higher rates of readmission among patients discharged on the weekend illustrate variability in care providing opportunities for improvement (Anthony et al., 2005).
It was no surprise when reports showed that nearly 20% of patients suffered an adverse event after hospital discharge, many of which were preventable or ameliorable (Forster et al., 2003). Half of patients take their medicines incorrectly after discharge and 30% have an adverse event related to medicines within 30 days (Kripalani et al., 2012). Those with communication deficits such a Limited English Proficiency (LEP) and those with low health literacy are more than two times more likely to suffer an adverse event (Bartlett et al., 2008).
Table 1. ReEngineered discharge (RED) checklist
1. Provide a written discharge plan that the patient can understand (e.g., the RED After Hospital Care Plan)
2. Determine need for and obtain language assistance.
3. Involve the Family Caregiver in discharge planning
4. Provide education about diagnosis
5. Medication reconciliation and education
6. Arrange follow-up appointments that the patient can keep
7. Assess patient understanding and arrange alternatives if the patient does not understand (Teach Back)
8. Create a follow-up plan for outstanding labs and tests
9. Organize post-discharge services and equipment
10. Reconcile discharge plan with national guidelines
11. Explain common problems and what to do if problem arises
12. Send the discharge summary to PCP within 2 days
13. Provide meaningful telephone reinforcement 2 days after discharge |
In this setting poor standardization and quality, Jencks et. al. reported in the New England Journal of Medicine in 2009 that 1 in 5 Medicare fee-for-service beneficiaries are readmitted within 30 days of discharge, and only half of those readmitted patients have a post-discharge visit before readmission (2009).