# Presentation: 701488

## Spotlight Case December 2004

**Discharge Fumbles**

## Source and Credits

- This presentation is based on the Dec. 2004 AHRQ WebM&M Spotlight Case in Hospital Medicine
- See the full article at _[http://webmm.ahrq.gov](http://webmm.ahrq.gov/)_
- CME credit is available through the Web site
- Commentary by: **Alan Forster**, **MD**, University of Ottawa
- Editor, AHRQ WebM&M: Robert Wachter, MD
- Spotlight Editor: Tracy Minichiello, MD
- Managing Editor: Erin Hartman, MS

## Objectives

*	**At the conclusion of this educational activity, participants should be able to:*
- List the types of adverse events that occur at discharge
- Identify the characteristics that identify patients at high risk for errors at discharge
- Understand the provider’s role in reducing adverse events at discharge
- Create an action plan for patient, provider and institutions to improve patient safety at discharge

## Case #1: Discharge Fumbles

*	**A 59-year-old man with severe but well-controlled congestive heart failure, on spironolactone and other appropriate medications, was discharged following a brief hospitalization for leg cellulitis. His pre-admission medication regimen was included on his discharge orders. Within days of discharge, the patient began to feel lethargic and nauseated. *

## Case #1 (cont.): Discharge Fumbles

*	**He presented to the emergency department (ED) and was found to be in acute renal failure, with a serum potassium level of 7.1 and a sodium level of 122. Upon review of his discharge orders, it was discovered that the spironolactone was mistakenly prescribed at a dose 8 times higher than his admission dose. *

## Case #2: Discharge Fumbles

*	**A patient was admitted for atypical chest pain. During the course of her stay, she was evaluated by neurology for memory deficit. She was placed on Reminyl (galantamine hydrobromide, a medication for Alzheimer’s disease), 4 mg twice daily to be increased to 8 mg twice daily in one month. Upon discharge, an order was written to “discharge on current medications.”*

## Case #2 (cont.): Discharge Fumbles

*	**The patient presented to the ED the following day with mental status changes. She was found to be profoundly hypoglycemic. Review of her discharge medications revealed an inadvertent addition of Amaryl (glimepiride, a medication for diabetes). It was determined that the pharmacy mistook the original order for Reminyl as Amaryl. *

## Patient Safety at Discharge

- Medical errors in the early discharge period are exceedingly common
- 1 in 5 medical patients experiences an adverse event in the first several weeks after discharge
- 1/3 associated with disability
- 1/2 associated with need for additional health services

*Source: Forster AJ, et al. Ann Intern Med. 2003;138:161-7; **Forster AJ, et al. CMAJ. 2004;170:345-9.     *

## Types of Adverse Events at Discharge

- Adverse drug events
- Account for 2/3 of all adverse events
- Errors in drug ordering, prescription filling, or reaction to medication
- Nosocomial infections
- With shortened lengths of stay, often apparent only _after_ discharge
- Procedural complications
- ie, post-LP headache
- Diagnostic and therapeutic errors
- May be underestimated

**Notes:**
Note for speaker: explanation for underestimation of diagnostic and therapeutic errors:
Patients in the research studies were followed for, at most, one month.  This may be too short a follow-up duration to identify poor outcomes related to such errors.  For example, if a hospitalist fails to arrange appropriate follow-up for a patient with a solitary pulmonary nodule on CXR, it may be several months before the problem becomes clinically apparent.   Therefore, diagnostic and therapeutic errors may be even more common than we know right now.

## Patient Factors Associated with  Adverse Events at Discharge

- Increased length of stay
- Diagnosis of diabetes mellitus
- Number of medications at discharge
- Non-linear risk
- Risk stable until medications exceed 12, then increases exponentially

*Source: Forster AJ, et al. CMAJ. 2004;170:345-9; **Forster AJ, et al. J Gen Intern Med. 2003;18(Suppl1):282.     *

## Medication Factors Associated with  Adverse Events at Discharge

- Patients unable to recall discussion with provider about side effects of medication are at 3 fold greater risk of adverse events
- Changes between pre- and post-discharge medication profiles
- Specific medications
- Corticosteroids, anticoagulants, diabetic medications, antibiotics, narcotic analgesics

*Source: Forster AJ, et al. J Gen Intern Med. 2003;18(Suppl1):282.     *

**Notes:**
3. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital discharge [abstract]. J Gen Intern Med. 2003;18(Suppl 1):282. 

## Communication with Follow-up Physicians

- Discharge summaries often delayed and incomplete
- In a recent audit, median delay between discharge and summary generation was 2 weeks
- Summaries often do not include test results, discharge medication list, or sufficient details about admission diagnosis or follow-up plans
- Discharge summaries not often distributed to all physicians caring for the patient
- Association between hospital readmissions and availability of discharge summary by follow-up physicians has been established

*Source: van Walraven, Weinberg AL. CMAJ. 1995;152:1437-42; **van Walraven, et al. J Gen Intern Med. 2002;17:186-92.     *

## Challenges in Follow-up

- Difficult for patients to contact physicians
- Patients unable to contact treating physician from hospital
- Patients unable to gain access to primary care physician in timely fashion
- Lack of infrastructure to closely follow patients after discharge
- No space on wards for hospital physicians to see patients in follow-up

*Source: Forster AJ, et al. J Gen Intern Med. 2003;138:161-7.     *

## Improving Patient Safety at Discharge

- One third of post-discharge events are preventable
- One third are considered ameliorable
- An event that is not preventable but whose severity could be reduced if corrective measures were instituted earlier and more effectively

**Notes:**
Note to author: please see below an example of ameliorable event:
 An example is a patient who develops c. difficile diarrhea following discharge.  Such an event is ameliorable if the diarrhea goes undetected by the health care team and is then complicated by severe dehydration or sepsis.  On the other hand if the diarrhea is picked up early and the patient responds to treatment, it will not be ameliorable.  

## What the Patient Can do to Improve Safety at Discharge

- Understand important new health problems and complications to watch for
- Know the follow-up plan and who to call if things go wrong
- Include family members in discussions with care providers and review of educational materials or patient teaching sessions

## How Providers Can Improve Safety at Discharge

- Recognize vulnerable patients
- Those on multiple or high-risk meds, with multiple diagnoses, or in hospital for long periods of time
- Arrange close follow-up
- Ask pharmacist to review medications with patient and family
- Phone follow-up MD prior to discharge to appraise of recent events
- Arrange home nursing visits

## What the System can do to Improve Safety at Discharge

- In-hospital care management with intensive nurse follow up
- Reduced number of hospital readmission for CHF patients
- Systematic follow-up phone calls to patients by pharmacist after discharge
- Reduced ED visits
- Automate discharge summaries
- Create hospital-based follow-up clinics on the medical ward

*Source: Weinberger M, et al. Med Care.1988;26:1092-102; Naylor MD, et al. JAMA. 1999;281:613-20; Naylor MD, McCauley KM. J Cardiovasc Nurs. 1999;14:44-54; Naylor MD. Nurs Res.1990;39:156-61; Nelson JR. Dis Mon. 2002;48:273-5; Dudas V, et al. Dis Mon. 2002;48:239-48; van Walraven, et al. CMAJ. 1999;160:319-26.        *

## Safety Checklist for Patient

*Do you understand why you were hospitalized, what your diagnosis is, and what treatments you received?*
*Are there any test results you are still waiting for? Who should you contact for those results?*
*Has a provider reviewed your medications with you? Do you know which of your home medications to continue, what the current doses are, and which you should stop taking?*
*Where and when are your follow-up appointments?*

## Safety Checklist for Patient (cont.)

*What are the warning signs of relapse or medication side effects you should look for?*
*Who should you contact if you are having difficulties? *
*Does your primary care physician know you were here and that you are leaving?*

## Safety Checklist for Provider

*Discharge medications*
*Review with the patient*
*Highlight changes from discharge*
*Specifically inform patient on side effects*
*Discharge summaries*
*Dictate in a timely fashion*
*Include discharge medications (highlight changes from admission)*
*List outstanding tests and reports that need follow up*
*Provide copies to all providers involved in the patient’s care*

## Safety Checklist for Provider (cont.)

*Communication with patient/family*
*Provide patient with medication instructions, follow-up details, and clear instructions on warning signs and what to do if things are not going well*
*Confirm that patient comprehends your instructions*
*Include a family member in these discussions*
*Communication with the primary physician*
*Call primary care physician prior to discharge*

## Safety Checklist for Provider (cont.)

*Follow up plans*
*Discharge clinic*
*Follow-up phone calls*
*Appointments/access to primary providers*