Inadequate hospital-discharge procedures can create a minefield of malpractice risks, as outlined in a recent report from the Pennsylvania Patient Safety Authority (PPSA).

“Discharge is a critical time, when patients who are leaving the hospital must know and understand how to take care of themselves once they are at home,” observes PPSA chair Ana Pujols-McKee, MD. “The data we received show there are a lot of issues that must be addressed.”

Her agency received more than 800 reports of botched discharges between June 2004 and December 2007. About 30% of these patients received no verbal or written instructions, according to the PPSA’s June 2008 Patient Safety Advisory.

Some patients received incomplete directions or prescriptions; others were given information or prescriptions meant for someone else. Several were discharged before receiving lab results that might have led to extended hospital stays.


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The advisory mentions one study that blamed sloppy discharges for a significant number of hospital re-admissions. Researchers interviewed 300 patients three weeks after they were discharged from an 800-bed urban teaching hospital. About 20% of these patients “had experienced an event that caused them harm,” Dr. Pujols-McKee reports.

One third of those events were preventable, and most resulted from inadequate communication between the health-care provider and the patient.

According to the PPSA, essential components of the discharge process are:

  • Educating the patient and his or her family, including a review of what to do if a problem occurs.
  • Scheduling follow-ups.
  • Organizing post-discharge plans.
  • Confirming the medication plan.
  • Giving written instructions.
  • A follow-up telephone call two or three days after discharge.

More risk-reduction recommendations appear in “Care at Discharge: A Critical Juncture for Transition to Posthospital Care,” an article within the June advisory. It is available at www.psa.state.pa.us.