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
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
Improving transitions in care
Ensuring safe care transitions requires a systematic approach.
Three key areas must be addressed prior to discharge:
reconciliation: Crosscheck the patient’s medications to
ensure that no chronic medications are stopped and to ensure
the safety of new prescriptions.
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.
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.