HARRISBURG, PA -- More than 800 reports submitted from hospitals from June 2004 to December 2007 to the Pennsylvania Patient Safety Authority show that a variety of problems occur when a patient is discharged from the hospital without proper instructions for care at home.

In approximately 30 percent of discharge-related reports from hospitals, the patient did not receive verbal or written discharge instructions before they left the hospital. In about 300 reports the Emergency Department was identified as the care area where the problems occurred and in about 500 reports the problems occurred when a patient was leaving after a hospital stay.

The data, released in the Authority's 2008 June Pennsylvania Patient Safety Advisory, identifies causes such as the patient knowingly leaving without written instructions (most often from the Emergency Department), instructions being incomplete or receiving another patient's instructions due to an error in the discharge process. Reports also show patients are receiving incomplete medication instructions, incomplete prescriptions or another patient's prescription or medication instructions. Reports indicate a number of patients were discharged before test results were made available to the patient's physician who may have delayed the discharge based on the final test results.

"Discharge is a critical time period when a patient who is leaving the hospital must know and understand how to take care of themselves once they are at home," Dr. Ana Pujols-McKee, chair of the Pennsylvania Patient Safety Authority said. "The data we received shows there are a lot of issues that must be addressed to improve the discharge process so that patients are not at risk of harm once they go home."

McKee cited a study mentioned in the Advisory showing that high rates of patients needing to be readmitted to the hospital are related to poorly conducted discharge processes. The study, conducted at an 800-bed urban teaching hospital found that about 20% of 300 patients interviewed three weeks after discharge from the hospital had experienced an event that caused them harm. One third of those events were preventable and most resulted from inadequate communication between the healthcare provider and the patient at the time of discharge.

McKee added that a large number of patients are also discharged or transferred to other facilities such as long term care or rehabilitation facilities which can increase the risks of misinformation or no information getting to the patient before they leave the facility. She said it is important for facilities to review their own discharge processes for any gaps.

"The Authority's main goal is to educate facilities to help them prevent medical errors," McKee said. "With the data, study results and risk reduction strategies outlined in the Advisory, facilities can take another look at their own data available to them through the reporting system and implement any necessary changes to their discharge processes to improve patient safety in their own facilities."

Along with the Advisory article and prevention advice, the Authority also provides facilities with a sample checklist to help staff assess that all discharge items are completed before the patient leaves the hospital. A consumer tip sheet is also available for patients to ensure they know what to expect at home before they leave the hospital.

For more information on the essential components of a discharge process and other risk reduction strategies go to the Pennsylvania Patient Safety Advisory article: "Care at Discharge-"Critical Juncture for Transition to Posthospital Care" go to the Authority's website at www.psa.state.pa.us.

The Authority's quarterly 2008 June Pennsylvania Patient Safety Advisory contains more articles developed from data submitted through real events that have occurred n Pennsylvania's healthcare facilities. The articles also provide advice and prevention strategies for facilities to implement within their own institutions.

Highlights in the June 2008 issue include:

- Hypothermia Before, During or After Surgery Increases Risks to Patients: More than 50 reports have been submitted to the Authority that show patients experiencing hypothermia before, during or after surgery. Few reports showed any measures in place to prevent the hypothermia. Elderly patients and children are most at risk of harm if hypothermia does occur. Risk reduction strategies are provided for facilities to consider.

- Sterile Water Poses Risks, Even Death If Given Intravenously: The Authority has received reports that show a failure among healthcare practitioners to recognize the danger of giving patients sterile water intravenously to treat patients with high levels of sodium in their blood. Bags of sterile water are being mistaken for IV solutions which can result in patient harm and even death. Recognizing the problem and developing protocols to treat patients with high sodium in their blood are some of the risk reduction strategies for facilities to consider.

- A Tear or Hole Made During A Routine Colonoscopy Can Be A Serious Complication: A review of studies in the medical literature involving tears or holes (or colon perforations) made during routine colonoscopies show the risk may be reduced if certain factors are identified prior to surgery.

- Falsely Elevated Blood Glucose Level Readings Can Lead to Incorrect Treatment Causing Harm or Even Death to Patients: Test results reading a false positive for high sugar levels can cause a patient to be treated incorrectly for high sugar and ultimately cause harm or even death to the patient as a report in PA-PSRS shows. Strategies for facilities to properly diagnose patients and other information are provided.

For a copy of the 2008 June Pennsylvania Patient Safety Advisory go to
http://www.psa.state.pa.us/psa/lib/psa/advisories/v5n2june_2008/
jun_2008_v5_n2.pdf

The Authority also released an article on Act 52 of 2007 detailing the Authority's role, progress to date and future goals. A wrong-site surgery quarterly update is also available in the 2008 June Advisory.

For more information on Act 52, wrong-site surgery updates or previous Patient Safety Advisories visit the Authority's website at www.psa.state.pa.us.