Hospital Discharge: One of the Most Dangerous Periods for PatientsCreated by:
Discharge from a hospital stay presents one of the most dangerous times for patients. Poor transitional care can be deadly, especially for patients with complex cases. Kaiser Health News recently published the results of its analysis of government inspection records related to patient discharge errors. This analysis revealed that, between January 2010 and July 2015, 3,016 home health agencies had insufficiently tracked or reviewed medications for new patients. Frequently, these home health providers failed to realize that their patients were taking dangerous drug combinations. Other medication mistakes were also prevalent. For example, one patient was given the deadly cancer drug methotrexate, instead of the diuretic metolazone, upon her discharge. She did not survive this mistake. Government inspectors noted that the most common issues among home health agencies were, in fact, failures in devising and implementing patient care plans. Failure to review medications was the second most prevalent error. Risk at the time of patient discharge may arise from the variety and number of different providers treating the patient, and errors can occur at any point during or after the discharge process. Federal data cited by Kaiser Health News found that fewer than half of discharged patients were confident in their understanding of their self-care instructions. A government report in 2013 also revealed that more than a third of nursing homes failed to properly assess patients’ needs, were unsuccessful in creating patient care plans, and did not follow these plans when they were put into place. Pharmacies, in turn, are an additional source for error, despite pharmacists taking a more active role in counseling patients and reviewing prescriptions. The number of providers, as well as episodic care provided to patients, can result in inadequate connection and communication failures between providers, as well as a lack of patient care coordination.