Posts Tagged discharge instructions
Medication mistakes are common. A recent study by Amanda Mixon following discharge from the hospital pegs the error rate at an astounding 50%. The study focused on whether instructions given to patients at the time of discharge from the hospital matched what the patient later took at home.
The study is biased by assuming all the errors are caused by patients — not the providers. The authors point to patient problems of low health literacy and a poor facility with numbers. Illegible instructions, poor communication skills, excessive complexity of medical regimens, conflicting instructions, and giving verbal instructions to the wrong person are all provider or institutional issues.
Even a simple phone call after discharge might have cleared up patient confusion — perhaps the study would have been better with a phone call and no phone call comparison.
The article conclusion is to apply more effort to find those high risk patients. Another conclusion would be to find those high risk hospitals having difficulty telling patients what drugs to take. The study was done at a VA facility affiliated with Vanderbilt — a good place to start the search.
Hospital medication errors are very frequent. A commonly quoted figure is one error every day of a hospitalization. Meaning: wrong drug or wrong dose or wrong time or missing dose.
Consequently, it should not come as a surprise the instructions patients are given when they are sent home have frequent errors. Patients may be taking medications before they are hospitalized, so in addition to new medications those pre-existing medications need to be considered (a process called “medication reconciliation”).
You may ask: how can this be goofed up? A person has medications at home, the doctor writes a new prescription just before going home, the prescription is filled by the local pharmacy, and the prescription is taken in addition to the same medications as before. What could be more simple?
The answer is: there is plenty of room for error! What if:
- the new medication is actually a generic duplicate of a brand name home medication
- the new medication has severe interactions with a home medication
- the home medication dose is listed incorrectly
- the new medication prescription and the discharge instructions don’t match
- a new medication prescription was omitted
- a doctor outside the hospital is unaware of the new medication and prescribes something that interacts badly
- the patient get an allergic reaction to the new medication but the prescriber is not available to help
- the patient forgot to mention some of the home medications
- unnecessary brand name drugs are prescribed that are not covered under the outpatient insurance plan
- the prescriber forgot to tell the patient to stop some of the home medications that were causing symptoms prior to hospitalization
NOT SIMPLE AT ALL.
Yet, hospitals and prescribers often don’t take much time to get the medications right at discharge (there is a big push to get the patient out the door as soon as possible). Here is an actual example from 2 weeks ago:
A patient was admitted from a care center with an accurate list of medications. The admitting nurse transcribed the list into the medical record but made a mistake on one dose. The physician’s plan was to reduce the does of another medication which seemed too strong but the patient was not taking any medications by mouth at that point so no medication orders were written. A few days later the patient was ready to leave the hospital.
Unfortunately, a different physician discharged the patient rather than the one that admitted the patient. The nurse’s list of home medications was used to generate the discharge medication instructions — no new medications were ordered. But, the transcription error of the nurse was included with the instructions and the plan to reduce the dose of another medications was forgotten. Two major errors. The family actually realized the errors but the nurse the family informed forgot to call the doctor so no change to the list was made so the care center followed the flawed instructions.
So what went wrong?
- Duplicate lists of home medications were collected but the transcription error was not detected because the lists were not compared.
- The list of medications used during the hospital stay was not marked as equal to or changed from home medications.
- The planned change in home medications was not made because there was no place to put such a reminder for discharge in the hospital chart.
- The prescriber did not review the medications with the patient or family personally.
Worse yet, although errors happened there was no plan to change the system to prevent similar errors in the future.
So, as a patient or family member what can you do?
- ALWAYS bring multiple copies of an accurate list of home medications to the hospital — give a list to anyone that asks to review the medications.
- Expect the attending physician to review the discharge instructions with the patient or appropriate family member — if this does not happen immediately complain and make that expectation known. Good physicians plan ahead and sometimes do this review the day before discharge!
- Use one of the copies of the home medication list to compare to the discharge instructions. Make sure to understand ANY changes. And ask — does the new medication, if any, interact with home medications?
- Find out who to call if questions or problems with the medications arise after getting home — get a name and phone number. Often the discharging nursing unit will take the call and find the right person.
The cause of hospital readmissions is not a secret. Patients are readmitted to the hospital because the patient, physician or both are too optimistic about the patient’s situation: too optimistic about the patient’s social problems, too optimistic about the strength of primary care, or too optimistic about the possibility of surgical complications.
It feels better to be Optimistic than the alternative. It feels better to the patient to be going home. It feels better to the doctor to believe all is well. But, the data about readmissions suggest the feelings are not always accurate. Perhaps we should be optimistic there are ways to find and correct the reasons for readmission. Providers need to focus on solving more problems before discharge, not just the problem of sending the patient out the door. Providers need to follow a discharge check list, just like a pilot getting ready for takeoff – not just be optimistic the plane will do just fine.
Rehospitalization is often attributed to fragmentation of health care. So, what constitutes a non-fragmented (smooth) transition from hospital to home? The following is the basis of that preflight checklist:
- The hospitalization is long enough to make sure the patient is stable.
- Providers anticipate the day of discharge:
- the likely date of discharge is discussed at least twice
- on the day of admission
- when the patient is feeling better, at least 48 hours before actual discharge
- patient questions are answered
- minimize medication complexity
- absolute minimum number of meds
- simplify dose schedule (don’t mix intervals)
- educate about new medications
- explain and write down
- the reason the patient was hospitalized
- the final diagnoses
- the name of surgery performed
- the complete list of medications including
- home meds discontinued
- home meds continued at same or different doses
- new meds (make sure they are generic or on the insurance formulary)
- why each medication is needed
- financial problems addressed (can medications be purchased?)
- home social situation reviewed
- obtain home monitoring equipment (glucose meters, scales, blood pressure checkers)
- send needed prescriptions to the patient’s pharmacy electronically
- the likely date of discharge is discussed at least twice
- family engaged, discharge plans discussed with family
- visiting nurses called if needed
- primary care providers called and discharge summary faxed same day
- discharge instructions reviewed verbally and in writing with patient
- follow up appointments made
- specialty care as needed
- primary care within one week
- transportation arranged
- phone follow-up next day by discharging provider
What indicates high risk for rehospitalization?
- Intensive care stay
- Living alone
- Previous readmissions
- Lack of insurance
- No primary care provider
- Smoking or other substance abuse
- Congestive heart failure
- COPD or asthma
- Insulin dependent diabetes
- Surgical wound drainage
- Weakness or falling
- Over 15 lb wt loss
- No phone at home
- No transportation (except ambulance)
Rehospitalization may be foreshadowed during a hospitalization. Health care providers sometimes fail to notice wound drainage, night time confusion, low grade fever, shortness of breath, leg swelling, anxiety, or comments about the cost of medications. The errors of omission can be reduced by minimizing provider changes and hand-offs — so patients do not “fall through the cracks”. Providers should take a second look at labs, vital signs and nursing notes before giving the green light for discharge.
Sarah Needleman of the Wall Street Journal was the author of “Rx to Avoid Health-Law Fines” which appeared August 8, 2013. She reported on new companies that help hospitals reduce hospital readmissions by printing sensible discharge instructions and also by predicting the chance of readmission to help focus resources on high risk patients.
Discharge software is expensive and probably not more effective than a good checklist of risks. Most importantly, hospitals must have action plans for each high readmission risk factor (like no transportation or no phone).
The Robert Wood Johnson Foundation published “The Revolving Door: A Report on U.S. Hospital Readmissions” in February 2013. The report puts a strong focus on fragmentation of care, being a root cause of rehospitalization. The fragmentation can be significantly reduced by strong primary care, doing close follow-up after discharge, engaging additional social services if needed, extensively using the phone to communicate with patients who have chronic illness.
A good idea: phone follow up. Many primary care providers complain that post hospital phone calls are an unreimbursed expenses (so they don’t make the calls) — hospitals should consider paying a fee to primary care for phone calls during the month after discharge.
Another good idea: the hospitalist outpatient check. Some hospitalist groups actually have a discharge follow-up clinic for patients who had a long hospitalization or who have rehospitalization risks. The visit is usually a couple of days after discharge and is focused on solving problems before they become big problems and also to make the transition to a new or existing primary care provider.