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.

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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.

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