From the 2018 HVPAA National Conference
Kshitij Thakur (Crozer-Chester Medical Center)
Effective post-discharge care transitions are important to providing safe, high-quality care. Studies have shown that up to 50% of patients experience at least one medical error at the time of discharge. Medical errors coupled with poor outpatient follow-up can lead to hospital re-admissions.
Within our internal medicine residency program we identified several common errors and barriers to a safe discharge. We wanted to explore how these issues compared with residents’ perception of the barriers to safe hospital discharge.
We retrospectively analyzed common interventions made by our transition of care nurse at the time of discharge follow up call (within 48 hours of discharge) over a period of 18 months. This identified common errors made during the discharge process like incorrect medication reconciliations, improper instructions etc. A survey instrument was constructed that included 6 questions to assess residents’ perceptions of common discharge errors. The survey was distributed to both Internal Medicine and Transitional Year residents.
The four most common discharge errors/barriers were found to be
1) Improper medication reconciliation/ medications not covered by patients insurance or unaffordable
2) Lack of information about follow up with a specialist.
3) No patient education about their discharge diagnosis
4) Lack of home care arrangements.
67% of residents completed the survey. Residents perceived medication reconciliation and lack of coordination to specialty care as the most common errors at the time of discharge. Majority of first year residents (interns) reported that they rarely scheduled a post hospital follow up visit before discharging the patient while the upper year residents regularly arranged for follow up appointments. Common barrier to scheduling was the lack of time and knowledge about role of hospital discharge follow ups among interns. Although the majority of the residents did report educating the patients about new medications and diagnoses they rarely considered the cost and insurance coverage of new medications at the time of discharge.
The study highlights that residents do have a good insight about common mistakes that occur at discharge. Since most of the discharge work is done by the interns who have the least training on transition of care, a knowledge gap has been identified. Currently the transition of care curriculum is focused on educating the upper year residents. Intern education about importance of proper transition of care via formal lectures and case audits has been introduced. Addressing transition of care as a part of daily rounds with the attending and upper year residents can prevent some of these errors. These changes are currently being implemented to ensure a safe discharge process.
Implications for the Patient
Errors made at the time of discharge can lead to poor outcomes. This study highlighted a knowledge gap among interns and led to introduction of a new curriculum for education about transition of care. We hypothesize that this intervention will lead to fewer discharge errors.