Postdischarge adverse events in the elderly.

Adverse events that occur after discharge from the hospital are a major public health concern that deservesmuchmore attention. During the last 2 decades, with the emergence ofmanaged care, there has been a progressive shortening of hospitalizations for patients. It is possible that elderly patients may be discharged from the hospital before they have fully recovered from their illness, with the accompanying potential to suffer adverse events. Recently, two studies conducted in theUnited States and Canada examined adverse events in patients discharged home from the general medicine services of major teaching hospitals. Although, these studies did not specifically examine a geriatric population, the United States study had a younger population (mean age, 57 years) and reported a 19% adverse event incidence rate compared with the Canadian study, which had an older population (mean age, 71 years) and reported a 23% adverse event incidence rate. These rates are approximately 5 to 6 times higher than the in-hospital adverse event incidence rates that were reported by the Harvard and the Utah and ColoradoMedical Practice Studies. Thus, adverse events seem to bemore likely to occur after hospital discharge, and as patients age, the rate of postdischarge adverse events is likely to increase. The scientific rationale for the occurrence of these postdischarge adverse events has been linked to discontinuities in care. Discontinuities or gaps in care occur in complex systems, such as the health care system, which involve the interaction of numerous professionals.8,9 The interdependency of health care activity and complexitywithin systems increases the potential for error, especiallywhenmultiple and expedient handoffs are necessary. The system of care may be most vulnerable at transitions, with discontinuities in care arising mainly from poor information transfer and faulty communication. Instances of poor information transfer and faulty communication occur at numerous points in the continuum of care, such as between inpatient and outpatient pharmacies, as a result of unstructured physician discharge summaries and unstructured cross-coverage physician sign-outs, during the discharge planning process and in follow-up of abnormal laboratory test results. The most common types of adverse events identified in the United States and Canadian studies within 3 to 4 weeks after hospital discharge were due to medications (66%Y72%), procedures (7%Y17%), therapeutic errors (16%), nosocomial infections (5%Y11%), pressure ulcers (7%), diagnostic errors (6%), and falls (2%Y4%). In these studies, approximately one-third of these adverse events were preventable (an adverse event injury that could have been avoided as a result of an error or a system design flaw), and another third were ameliorable (an injury whose severity could have been substantially reduced if different actions or procedures had been performed or followed). Twenty-five to thirty percent of adverse events in these studies were associated with a nonpermanent disability, 3% resulted in permanent disabilities, and 3% resulted in death. Of the adverse events resulting in at least a nonpermanent disability, 48% were preventable, and 24% were ameliorable. Also within 3 to 4 weeks after hospital discharge, 9% to 21% of patients in these studies had an additional physician visit, 5% required laboratory monitoring in addition to their physician care, 11% to 12% had an emergency department visit, and 17% to 24% had a hospital readmission. Thus, postdischarge adverse events may lead to serious disability or even death, and most are either preventable or ameliorable. Geriatric syndromes such as falls, delirium, pressure ulcers, and underfeeding have often been viewed as preventable adverse events that may occur in the elderly during transitions of care. For example, the United States study noted above reported 2 of 3 falls experienced by postdischarge patients as preventable. If these geriatric syndromes are to be viewed as preventable adverse events, then their prevention will require a systems-based approach to care. Geriatricians have made substantial efforts to improve systems of care for the elderly by developing innovative management programs. Examples of geriatric management programs include Acute Care for the Elderly units, Delirium Intensive Care, and Delirium and Falls teams, EDITORIAL