Safety concerns should not end with discharge

Preventing errors after patients return home

The transition from hospital to home is a potentially vulnerable period, and the medical community should explore ways to reduce adverse events during this transition, say the authors of a new study in the Annals of Internal Medicine.

The study looked at 400 consecutive patients discharged home from an urban teaching hospital in Canada. Researchers focused on adverse outcomes, which they defined as "either new or worsening symptoms, unanticipated visits to health care facilities for tests or treatment, or death."1

The study found that 76 patients had adverse events after discharge, which were defined by the authors as "an injury resulting from medical management rather than the underlying disease."1 The researchers included adverse events that happened in the hospital as well as after discharge, as long as the symptoms persisted until the patient went home. These adverse events were further broken down as follows:

  • Preventable adverse events (23): Injuries that could have been avoided — judged to be the probable result of an error or a system design flaw.
  • Ameliorable adverse events (24): Injuries whose severity could have been substantially reduced if different actions or procedures had been performed or followed.

"A preventable adverse event might involve a patient discharged on supplements with no monitoring of electrolytes," explains Alan J. Forster, MD, FRCPC, MSc, of the University of Ottawa and lead author of the study. An ameliorable adverse event, he suggests, might involve sending home a patient on certain meds who experienced wheezing that persisted longer than normal, but who received inadequate monitoring.

Adverse drug events were the most common type of adverse event (66%), followed by procedure-related injuries (17%).

Under-recognized problem

The study was undertaken, the authors write, because they suspected that adverse events after discharge was an underappreciated (and understudied) problem.

Referring specifically to the Institute of Medicine report, To Err is Human, the researchers noted that it "may underestimate the overall safety problem, since injuries occurring after discharge were not included in the evaluation. Patients may be especially vulnerable to injuries during this period because they still may have functional impairments and because discontinuities may occur at the interface of acute and ambulatory care."1 They went on to point out, however, that few studies were available to estimate the extent of the problem.

"We speculated in our introduction that the problem could mainly be due to poor organization of care," Forster adds. "But we did not want to blame a group of people or any one specialty. The fact that multiple physicians look after patients over time and in different places clearly makes communication of the care plan difficult, as well as the identification of responsibilities. In fact, it often makes patients quite confused over who makes which decisions," he says.

Seeking prevention

This did not prevent the authors from concluding, however, that many of the noted adverse events "could potentially have been prevented or ameliorated with simple strategies."1 They didn’t stop with that observation, however. "For the preventable and ameliorable adverse events, we asked our researchers to identify ways they could be prevented and/or ameliorated," Forster notes.

Here are some of the general themes common to their recommendations:

  • Identifying unresolved issues at the time the patient leaves the hospital.

    It’s important to conduct a very thorough assessment to determine what issues remain unresolved and need to be monitored, Forster says. "It may not be necessary for the patient to remain hospitalized, but there may still be questions that remain unanswered, so the patient should be monitored closely."

  • Patients must learn more about their meds.

    Patients must know their meds, their potential side effects, and what to do when problems arise. This education should take place before they leave the hospital. "Quite often, patients are in the hospital for a short time, but meds can change quite a lot," Forster says.

    "When they leave, even though you may have spent some time teaching them about their meds, they often forget," he adds." There should be some system in place to make sure they have learned about their meds, and that they have access to help when they come across problems."

  • Improved recognition of monitoring responsibility.

    It must be very clear just who is responsible for the monitoring of the drugs, says Forster. "If a patient is sent home on an anticoagulant, who is responsible?" he poses. "Quite often, the hospital physician might assume it’s the primary care doc, and vice versa."

Putting a system in place

In general, facilities need to have a better system for identifying general problems and for dealing with common questions and concerns, Forster says. "There has to be an easy mechanism of communicating back to the hospital; maybe one phone number to call," he offers. "Maybe a callback from the ward, the nurse, or even the pharmacy might be useful."


1. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003; 138:161-167.

For more information, contact:

• Alan J. Forster, MD, FRCPC, MSc, University of Ottawa, F654-1053 Carling Ave., Ottawa, Ontario K1Y 4E9, Canada. Telephone: (613) 722-7000.