In this study, we identified at least one medication discrepancy in three out of four admissions to a SNF for subacute care. This represented over one-fifth of all medications prescribed on SNF admission. Disagreement between the discharge summary and patient care referral form occurred in over 50% of admissions and accounted for over 60% of all medication discrepancies. Our findings have important implications for patient safety and hospital practice.
Upon transfer between institutions, a discharging institution typically lists the discharge medication regimen on two documents: the discharge summary and the patient care referral form. In some cases, a copy of the medication administration record from the discharging facility is also provided. In our study, we found that the medication regimens did not match between the discharge summary and patient care referral form in over 50% of all SNF admissions. This is partially explained by dictation and transcription errors known to occur in discharge summaries.13
Although they are meant to be reviewed, corrected, and signed prior to transmission, this often does not occur. However, apart from transcription errors, discharge summaries often contain missing or incorrect medication information, with one review estimating the prevalence of errors ranging from 2–40% (median 21%).14
Hospital physicians should take care to ensure that the medication information contained in the discharge summary is correct at the time of discharge.
The inpatient clinical workflow may also explain some of discrepancies between the discharge summary and the patient care referral form. While the patient care referral form is typically completed on the day of actual discharge, the discharge summary may be completed in anticipation of a discharge, in some cases up to 24 h in advance. Further, cancelled or delayed discharges because of deterioration in a patient’s condition necessitate that a previously dictated discharge summary be updated prior to the actual discharge. In such cases, hospital physicians should exercise great care to update the discharge medication list as well as the hospital course. Whether intentional or not, any disconnect in the timing of the completion of the discharge summary and the patient care referral form likely contributes to discrepancies between them. Changing the clinical workflow to coordinate the completion of the patient care referral form with the discharge summary can enhance their consistency.
The prevalence of medication discrepancies observed in our study is comparable to findings of discrepancies in the inpatient setting upon discharge, with other studies reporting a range of 40–70% medication discrepancies in the discharge summary.7,8,15
One study of 253 hospitalized patients found 99 drug-therapy inconsistencies and omissions requiring pharmacist intervention prior to discharge.16
Another study reported a mean number of discharge medication discrepancies of 3.3 per patient,17
a finding similar to our estimate of 3.5 discrepancies per patient admission.
The clinical importance of the medication discrepancies identified in our study might be inferred by examining the types of medications involved in the discrepancies. Over 50% of all 495 discrepant medications were for cardiovascular agents, opioid analgesics, neuropsychiatric agents, hypoglycemics, antibiotics, and anticoagulants. A minority of discrepant medications involved as-needed medications (n
91) or bowel agents (n
48); the majority of discrepancies were for medications meant to be prescribed on a scheduled basis. Although some might consider discrepancies among prn
or bowel agents as trivial, we caution against dismissing the importance of discrepancies for prn
or bowel agents to the care of the patient. If we consider a medication as “essential” if their sudden withdrawal or change increases the risk of adverse health events, such as hospitalization or emergency department visits,18,19
then stool softeners are essential when co-administered with a narcotic analgesic. Indeed, constipation due to opioid analgesics is an important adverse event affecting many patients after hospital discharge.20
Although we did not directly measure harm attributable to medication discrepancies in our study, there is overlap between the types of medication discrepancies found in our study and medications linked to adverse drug events. Changes and discontinuations of medications, such as metoprolol, colchicine, metoclopromide, risperidone, warfarin, insulin, and codeine, in patients transferred between acute and long-term care facilities contributed to a 4.4% risk of ADEs per drug alteration in one study.21
A similar array of drugs (antibiotics, corticosteroids, cardiovascular drugs, analgesics, and anticoagulants) were implicated in one quarter of hospital readmissions for patients with adverse events following hospital discharge in another study.22
Given the risk of ADEs associated with drug alterations and the risk of readmission associated with posthospital ADEs, the medication discrepancies identified in our study posed potential for harm to our study population.
The limitations of our study deserve comment. First, our study is geographically limited to two long-term care-based SNFs in central Massachusetts with patient populations that were predominantly white. This limits the generalizability of our findings to SNFs based in acute care facilities or to other geographic regions who may serve more racially diverse patient populations. Also, we have limited information about the medications without discrepancies, and therefore cannot determine whether certain medication classes are more or less likely to have a medication discrepancy when actually prescribed. The frequency of classes observed in our study likely reflects the frequency of prescribing of those medications upon admission to SNF in general.
Our findings have several implications. First, SNF nurses are faced with the daily task of reconciling discrepant documentation from other hospitals. Although nurses recognize the importance of medication reconciliation, they are often faced with time constraints related to obtaining better information about patient medications. Finding the time to complete the medication reconciliation by calling the discharging hospital to clarify medications can be a challenge, particularly during night shifts and weekends. Because the Joint Commission is requiring medication reconciliation in SNFs for accreditation in 2009, many skilled nursing facilities are adopting medication reconciliation processes. In this way, nursing staff can lead the processes to improve medication reconciliation with the goal of decreasing unresolved medication discrepancies during transitional care. However, many SNFs do not maintain Joint Commission accreditation and likely lag in their medication reconciliation processes. In these cases, many discrepancies are likely going unnoticed and may be contributing to compromised patient safety.
It is therefore incumbent upon discharging hospitals and their physicians to ensure consistency in their discharge documentation. It would also be helpful for hospital physicians to document reasons for changes to previous medication regimens (e.g., home medications) so that SNF physicians can optimally manage the handoff to the primary care physician at the appropriate time.14
Hospital physicians should realize that there is often a vulnerable 24–48 h period following SNF admission when the patient waits to be seen by a SNF admitting physician. Upon admission, medication orders are typically reviewed by the SNF nurse and verified on the telephone by a covering provider unfamiliar with the patient. It may take up to 48 h before the patient and medical record are evaluated by the SNF physician. During this period, medication errors and adverse events may be more likely to occur despite efforts by the SNF admitting team to clarify medications with the community primary care physician or the hospital team.
Our study underscores the importance of current efforts to improve communication between providers upon transition of care23,24
and the need to improve transitions from hospitals to SNF. Even in systems with electronic messaging between hospital caregivers and physicians assuming post-discharge patient care, poor inter-institutional communication was the factor most commonly associated with preventable adverse events.19
As such, the Medicare Payment Advisory Commission has identified the need to improve inter-institutional provider communication, including improving inadequate discharge summary information, as an important strategy to reduce readmissions.25
Since SNF policies are driven by state and federal regulations, we argue that state policies to improve the consistency and completeness of inter-institutional communication forms may have a greater effect on reducing potential medication discrepancies during inter-institutional transfers than Joint Commission medication reconciliation efforts alone. Further, we recommend that efforts such as the Society of Hospital Medicine’s development of a “Discharge Checklist for Hospitalists” targeting transition of care from the hospital to the community be replicated for inter-institutional transfers.23
In this way, health-care providers across the spectrum of care can improve the quality of inter-institutional documentation to prevent medication discrepancies at transfers of care.