From June 2004 to December 2007, more than 800 reports were submitted through the Pennsylvania Patient Safety Reporting System (PA-PSRS) identifying a variety of problems occurring at discharge. The emergency department (ED) was identified as the care area in more than 300 reports. Approximately 500 reports were submitted from inpatient care areas. Less than 1% of reports were submitted by ambulatory surgical facilities. Approximately 30% of all reports indicated patients left the facility without receiving verbal and/or written discharge instructions.
The causes identified indicate patients knowingly left without written instructions (most often from the ED), did not receive complete instructions, or received another patient's instructions due to an error in the discharge process. Lack of medication reconciliation was also evident in the reports, including issues such as a patient receiving incomplete medication instructions, incomplete prescriptions, or another patient's prescriptions or instructions. Many patients did not have their intravenous (IV) access removed prior to leaving the ED or other inpatient care area. The PA-PSRS reports indicated some patients returned to the hospital with an IV site infection and/or phlebitis. Additionally, reports indicated patients were discharged prior to test results being made available to the attending physician who might have postponed the discharge based on the final results.
The narratives below illustrate some of the issues reported through PA-PSRS.
Patient discharged to nursing home. Discharge orders for 50 mg fentanyl but were written as 500 mg. The nursing home did not catch error until patient became very drowsy. Narcan was administered.
Patient brought to [emergency room (ER)] by parent with [chief complaint] of [shortness of breath] for the last 24 hours. Patient diagnosed with exacerbation of asthma. Discharge instructions written along with [prescriptions]. Patient's nurse tied up with another patient. All staff were busy, and the ER was full. Patient and parent were witnessed leaving ER. Phone call was made to home, and [patient and parent were] encouraged to return for instructions and prescriptions. Patient never picked up documents.
Patient was discharged with the wrong discharge medication list. The discharge medication list was for another patient.
Patient was admitted with diagnosis of thrombus right arm. An x-ray of right elbow was ordered. Patient was discharged to an extended care facility via ambulance before right elbow x-ray done. Orthopedic doctor was notified of x-ray not being done.
Patient was discharged to another facility with the right femoral triple lumen catheter still in place. Staff from the other facility called asking how long and how much pressure to hold on the femoral site when removing the catheter.
Family member called this nursing unit stating the discharge instructions were unclear. The nurse discovered the medication discharge instructions were not completed. The patient had received a coronary artery stent and the booklet was still with the chart. The daughter was also unclear of the pacemaker instructions. [She was] also unclear on length of time the antibiotic was to be continued.
Excerpted from: Care at discharge—a critical juncture for transition to posthospital care. Pa Patient Saf Advis 2008 Jun. http://patientsafety.pa.gov/ADVISORIES/Pages/200806_39.aspx.