Adverse Events after Hospital Discharge
Background
Being discharged from the hospital can be dangerous. A classic study found that nearly 20% of patients experience adverse events within 3 weeks of discharge, nearly three-quarters of which could have been prevented or ameliorated. Adverse drug events are the most common postdischarge complication, with hospital-acquired infections and procedural complications also causing considerable morbidity. More subtle discharge hazards arise from the fact that nearly 40% of patients are discharged with test results pending, and a comparable proportion are discharged with a plan to complete the diagnostic workup as an outpatient, placing patients at risk unless timely and complete follow-up is ensured. As nearly 20% of Medicare patients are rehospitalized within 30 days of discharge, minimizing post-discharge adverse events has become a priority for the US health care system.
Systematic problems in care transitions are at the root of most adverse events that arise after discharge. Discontinuity between inpatient and outpatient providers is common, and studies have shown that 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. Lack of medication reconciliation results in the potential for inadvertent medication discrepancies and adverse drug events—particularly for patients with low health literacy, or those prescribed high-risk medications or complex medication regimens.
Source: Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424-429. [go to PubMed]
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. Finally, the fragmented nature of the health care system may limit individual hospitals' incentive to improve their discharge process, despite the benefits to patients that may result.
Preventing Adverse Events after Discharge
Ensuring safe care transitions requires a systematic approach. Three key areas must be addressed prior to discharge:
Evaluating the magnitude of care transition problems and the effect of interventions is hampered by the lack of a standard outcome measurement. Hospital readmission rates are often used, but most adverse events after discharge cause patient harm without requiring readmission. A three-item patient survey measure has been developed to measure patient satisfaction with the transition process; hospitals are being encouraged to add these items to standard patient satisfaction questionnaires.
Current Context
A variety of policy initiatives have been implemented in order to encourage hospitals to address adverse events and readmissions after discharge. The Centers for Medicare and Medicaid Services began publicly reporting hospital readmission rates for certain conditions in 2009. The Patient Protection and Affordable Care Act of 2010 contains multiple payment reforms intended to promote hospital efforts to address and prevent adverse events after discharge. Chief among these are financial penalties for hospitals with above-average readmission rates for target illnesses. Since those penalties were implemented in 2012, more than 2200 hospitals had up to 2% of their annual Medicare reimbursements withheld due to excess readmissions. Hospitals now also receive "bundled" payments for target illnesses that cover all costs associated with patient care for a 30-day period, providing a financial incentive to ensure continuity of care.
Being discharged from the hospital can be dangerous. A classic study found that nearly 20% of patients experience adverse events within 3 weeks of discharge, nearly three-quarters of which could have been prevented or ameliorated. Adverse drug events are the most common postdischarge complication, with hospital-acquired infections and procedural complications also causing considerable morbidity. More subtle discharge hazards arise from the fact that nearly 40% of patients are discharged with test results pending, and a comparable proportion are discharged with a plan to complete the diagnostic workup as an outpatient, placing patients at risk unless timely and complete follow-up is ensured. As nearly 20% of Medicare patients are rehospitalized within 30 days of discharge, minimizing post-discharge adverse events has become a priority for the US health care system.
Systematic problems in care transitions are at the root of most adverse events that arise after discharge. Discontinuity between inpatient and outpatient providers is common, and studies have shown that 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. Lack of medication reconciliation results in the potential for inadvertent medication discrepancies and adverse drug events—particularly for patients with low health literacy, or those prescribed high-risk medications or complex medication regimens.
Source: Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424-429. [go to PubMed]
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. Finally, the fragmented nature of the health care system may limit individual hospitals' incentive to improve their discharge process, despite the benefits to patients that may result.
Preventing Adverse Events after Discharge
Ensuring safe care transitions requires a systematic approach. Three key areas must be addressed prior to discharge:
- Medication reconciliation: The patient's medications must be cross-checked to ensure that no chronic medications were stopped and to ensure the safety of new prescriptions.
- Structured discharge communication: Information on medication changes, pending tests and studies, and follow-up needs must be accurately and promptly communicated to outpatient physicians.
- Patient education: Patients (and their families) must understand their diagnosis, their follow-up needs, and whom to contact with questions or problems after discharge.
Evaluating the magnitude of care transition problems and the effect of interventions is hampered by the lack of a standard outcome measurement. Hospital readmission rates are often used, but most adverse events after discharge cause patient harm without requiring readmission. A three-item patient survey measure has been developed to measure patient satisfaction with the transition process; hospitals are being encouraged to add these items to standard patient satisfaction questionnaires.
Current Context
A variety of policy initiatives have been implemented in order to encourage hospitals to address adverse events and readmissions after discharge. The Centers for Medicare and Medicaid Services began publicly reporting hospital readmission rates for certain conditions in 2009. The Patient Protection and Affordable Care Act of 2010 contains multiple payment reforms intended to promote hospital efforts to address and prevent adverse events after discharge. Chief among these are financial penalties for hospitals with above-average readmission rates for target illnesses. Since those penalties were implemented in 2012, more than 2200 hospitals had up to 2% of their annual Medicare reimbursements withheld due to excess readmissions. Hospitals now also receive "bundled" payments for target illnesses that cover all costs associated with patient care for a 30-day period, providing a financial incentive to ensure continuity of care.
What's New in Adverse Events after Hospital Discharge on AHRQ PSNet
NEWSPAPER/MAGAZINE ARTICLE
How to make surgery safer.
Landro L. Wall Street Journal. February 16, 2015.
AUDIOVISUAL PRESENTATION
Report suggests trend in prescription drug errors filled by pharmacists.
McKinnon C. WBZ-TV. February 13, 2015.
NEWSPAPER/MAGAZINE ARTICLE
Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices.
ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5.
PRESS RELEASE/ANNOUNCEMENT
AHRQ Announces Interest in Research About the Epidemiology of Patient Safety Risks and Harms in Ambulatory Health Care Settings.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. February 10, 2015. Publication No. NOT-HS-15-006.
STUDY
Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study.
Rhodes P, Campbell S, Sanders C. Health Expect. 2015 Feb 3; [Epub ahead of print].
STUDY
Medication-related emergency department visits in pediatrics: a prospective observational study.
Zed PJ, Black KJL, Fitzpatrick EA, et al. Pediatrics. 2015 Feb 2; [Epub ahead of print].
STUDY
Use of quality indicators to compare point-of-care testing errors in a neonatal unit and errors in a STAT central laboratory.
Cantero M, Redondo M, Martín E, Callejón G, Hortas ML. Clin Chem Lab Med. 2015;53:239-247.
How to make surgery safer.
Landro L. Wall Street Journal. February 16, 2015.
Report suggests trend in prescription drug errors filled by pharmacists.
McKinnon C. WBZ-TV. February 13, 2015.
Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices.
ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5.
AHRQ Announces Interest in Research About the Epidemiology of Patient Safety Risks and Harms in Ambulatory Health Care Settings.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. February 10, 2015. Publication No. NOT-HS-15-006.
Trust, temporality and systems: how do patients understand patient safety in primary care? A qualitative study.
Rhodes P, Campbell S, Sanders C. Health Expect. 2015 Feb 3; [Epub ahead of print].
Medication-related emergency department visits in pediatrics: a prospective observational study.
Zed PJ, Black KJL, Fitzpatrick EA, et al. Pediatrics. 2015 Feb 2; [Epub ahead of print].
Use of quality indicators to compare point-of-care testing errors in a neonatal unit and errors in a STAT central laboratory.
Cantero M, Redondo M, Martín E, Callejón G, Hortas ML. Clin Chem Lab Med. 2015;53:239-247.
Recurrent Hypoglycemia: A Care Transition Failure?
Ted Eytan, MD, MS, MPH. AHRQ WebM&M [serial online]. October 2008
Care Transitions.
Sunil Kripalani, MD, MSc. AHRQ WebM&M [serial online]. December 2007
In Conversation with...Eric Coleman, MD, MPH.
AHRQ WebM&M [serial online]. December 2007
Discharging Our Responsibility.
Gregg C. Fonarow, MD. AHRQ WebM&M [serial online]. September 2007
Discharged Blindly.
Lisa I. Iezzoni, MD, MSc. AHRQ WebM&M [serial online]. December 2005
Ted Eytan, MD, MS, MPH. AHRQ WebM&M [serial online]. October 2008
Sunil Kripalani, MD, MSc. AHRQ WebM&M [serial online]. December 2007
AHRQ WebM&M [serial online]. December 2007
Gregg C. Fonarow, MD. AHRQ WebM&M [serial online]. September 2007
Lisa I. Iezzoni, MD, MSc. AHRQ WebM&M [serial online]. December 2005
Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals.Feigenbaum P, Neuwirth E, Trowbridge L, et al. Med Care. 2012;50:599-605.
Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers.Were MC, Li X, Kesterson J, et al. J Gen Intern Med. 2009;24:1002-1006.
Jack BW, Chetty VK, Anthony D, et al. Ann Intern Med. 2009;150:178-187.
Moore C, McGinn T, Halm E. Arch Intern Med. 2007;167:1305-1311.
Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. JAMA. 2007;297:831-841.
The care transitions intervention: results of a randomized controlled trial.Coleman EA, Parry C, Chalmers S, Min SJ. Arch Intern Med. 2006;166:1822-1828.
Posthospital medication discrepancies: prevalence and contributing factors.Coleman EA, Smith JD, Raha D, Min S. Arch Intern Med. 2005;165:1842-1847.
Patient safety concerns arising from test results that return after hospital discharge.Roy CL, Poon EG, Karson AS, et al. Ann Intern Med. 2005;143:121-128.
The incidence and severity of adverse events affecting patients after discharge from the hospital.Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Ann Intern Med. 2003;138:161-167.
Oakbrook Terrace, IL: The Joint Commission; 2015.
Alderman L. New York Times. June 18, 2010;B6.
McLean, VA: National Patient Safety Foundation.
Aurora, CO: The Division of Health Care Policy and Research, University of Colorado Health Sciences Center.
Jack B, Paasche-Orlow M, Mitchell S, Forsythe S, Martin J. Rockville, MD: Agency for Healthcare Research and Quality; March 2013. AHRQ Publication No. 12(13)-0084.
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