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Error Alert: Discharging Patients Who Do Not Understand Their Discharge Medications

March 04, 2016


Despite the importance of teaching patients about the medications to take after discharge, studies suggest healthcare providers are not successfully preparing patients for the transition home. Between 30% and 70% of patients make a medication error in the immediate weeks following hospitalization, and the Centers for Medicare & Medicaid Services reports an average national hospital readmission rate of 17.5% to 19.5%.

The discharge process is often rushed and interrupted, making it difficult to ensure patients know which medications to take, the correct doses, and how to take them after discharge. Immediately prior to discharge is not an ideal time for education either as patients may be overwhelmed with the amount of information being provided at once. A recent study of patients with acute coronary syndrome or heart failure found that more than half of the hospitalized patients were either taking a previously prescribed medication that should have been discontinued (36%) or not taking a newly prescribed medication listed on the discharge medication list (27%). More than half of all discharged patients (59%) also misunderstood the indication, dose, or the frequency of use of the prescribed medications.

Medication errors that occur during the first few weeks after discharge from the hospital can cause significant harm. In fact, one study showed that almost a quarter of all post-discharge errors were considered serious or life-threatening, and most of those errors happened within the first 14 days after discharge. The highest predictors of post-discharge errors included low health literacy and low subjective numeracy (self-reported measure of the ability to perform mathematical tasks and the preference for numerical versus prose [words] information). Interestingly, numeracy was not specifically associated with misunderstandings in the numerical aspects of medications such as dose or frequency, but rather with taking a medication no longer prescribed, omitting a prescribed medication, or misunderstanding a medication’s indication. No association was found between errors and educational attainment, the number of medications being taken, medications changed during hospitalization, poor social support, or low preadmission medication adherence. Perhaps this risk is best addressed with a redesigned discharge process that facilitates the most effective means of teaching patients about their medications, initiating education earlier in the hospital stay, and providing post-discharge support. 

Are pharmacists involved in discharge education in your facility? Which medications are of particular concern for patients being discharged?


Matthew Grissinger, RPh, FISMP, FASCP, is the Director of Error Reporting Programs at the Institute for Safe Medication Practices.



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