News | June 25, 2008

Pennsylvania Patient Safety Authority Data Shows Incomplete Discharge May Lead to Patient Harm

June 26, 2008 - More than 800 reports submitted from hospitals from June 2004 to December 2007 to the Pennsylvania Patient Safety Authority show a variety of problems occur when a patient is discharged from the hospital without proper instructions for care at home.

In about 30 percent of discharge-related reports from hospitals, the patient did not receive verbal or written discharge instructions before they left the hospital. In about 300 reports the emergency department was identified as the care area where the problems occurred and in about 500 reports the problems occurred when a patient was leaving after a hospital stay.

The data, released in the authority's 2008 June Pennsylvania Patient Safety Advisory, identifies causes such as the patient knowingly leaving without written instructions (most often from the emergency department), instructions being incomplete or receiving another patient's instructions due to an error in the discharge process. Reports also show patients are receiving incomplete medication instructions, incomplete prescriptions or another patient's prescription or medication instructions. Reports indicate a number of patients were discharged before test results were made available to the patient's physician who may have delayed the discharge based on the final test results.

"Discharge is a critical time period when a patient who is leaving the hospital must know and understand how to take care of themselves once they are at home," said Dr. Ana Pujols-McKee, chair of the Pennsylvania Patient Safety Authority. "The data we received shows there are a lot of issues that must be addressed to improve the discharge process so that patients are not at risk of harm once they go home."

McKee cited a study mentioned in the advisory showing that high rates of patients needing to be readmitted to the hospital are related to poorly conducted discharge processes. The study, conducted at an 800-bed urban teaching hospital found about 20 percent of 300 patients interviewed three weeks after discharge from the hospital had experienced an event that caused them harm. One third of those events were preventable and most resulted from inadequate communication between the healthcare provider and the patient at the time of discharge.

McKee added a large number of patients are also discharged or transferred to other facilities, such as long term care or rehabilitation facilities, which can increase the risks of misinformation or no information getting to the patient before they leave the facility. She said it is important for facilities to review their own discharge processes for any gaps.

"The authority's main goal is to educate facilities to help them prevent medical errors," McKee said. "With the data, study results and risk reduction strategies outlined in the advisory, facilities can take another look at their own data available to them through the reporting system and implement any necessary changes to their discharge processes to improve patient safety in their own facilities."

Along with the advisory article and prevention advice, the authority also provides facilities with a sample checklist to help staff assess that all discharge items are completed before the patient leaves the hospital. A consumer tip sheet is also available for patients to ensure they know what to expect at home before they leave the hospital.

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