By Lisa Simm, RD, MBA, CPHQ, CPPS, CPHRM, FASHRM, and Ann Fiala, RN, BSN, CPHRM, CHC
Miscommunication contributes to a majority of malpractice issues. Although poor communication can occur at many points, it is especially likely when instructing patients about medications during care transitions from one setting to another. To minimize the potential for dangerous complications or the need for readmission, medical facilities must take steps to ensure clear communication practices.
During the patient’s hospital stay, healthcare staff have direct control over all medications taken. However, when a patient is discharged, this responsibility falls into the patient’s hands or into the hands of a caregiver. This transition provides ample opportunity for miscommunication:
- The patient may not clearly explain what medications are normally taken at home. This can happen for a number of reasons, from forgetting about a medication to not knowing its name. When the patient returns home and begins taking newly prescribed medications, harmful drug interactions can occur.
- The patient may not understand that new medications should replace old medications. Additionally, the patient may be reluctant to waste old medications and instead try to finish them. This can result in harmful drug interactions and duplicative therapy.
- The patient may not understand the instructions, which can result in taking a medication at the wrong frequency, dosage, or time.
- Verbal instructions may not be clear, or the patient may be confused and unable to remember them.
- Written instructions may not be clear. The inclusion of jargon, generic vs. brand names, sloppy handwriting, and uncommon abbreviations can make instructions difficult to read.
The importance of follow-up
Proper follow-up, including a call 24–48 hours after discharge and an in-person physician’s office appointment seven days after discharge, helps identify any developing issues before they become major problems. However, certain factors may hinder follow-up procedures:
- Patients may lack access to phones, computers, and other devices used for follow-up. In-person follow-up can also be complicated by a lack of transportation.
- Patients transitioning from nursing homes or other facilities may lack transportation. It is important to consider how the patient will get to the follow-up appointment.
- Generational preferences play a role in follow-up. Younger patients may not want to talk over the phone and prefer accessing their medication list through the patient portal, while older patients may prefer one-on-one conversations.
Medication reconciliation is essential, as discrepancies in the medications taken before, during, and after transitions in care can result in the wrong medication, dose, or adverse drug reactions. Lists should be thorough, including not only the name of the medication, but also its dosage and how often it is taken.
It is not enough to rely on the patient’s account of what medications are taken at home. Instead, it is necessary to implement a proven procedure that relies on multiple sources to verify the patient’s medication list, such as the Medications at Transitions and Clinical Handoffs (MATCH) toolkit from the Agency for Healthcare Research and Quality or the Medication Reconciliation Review tool from the Institute for Healthcare Improvement.
Implementing the following standardized best practices can improve communication:
- Provide instructions on old medications as well as new medications. If patients need to stop using an old medication or the dosage of a medication has changed, make sure they understand this.
- When providing oral instructions, use accepted teaching techniques, such as having the patient repeat the information to demonstrate understanding. Do the same for caregivers.
- When providing written instructions, use easy-to-understand language. The writing should not exceed an eighth-grade reading level, and a fourth-grade reading level may be more appropriate. Make sure the writing is fully legible.
- Use electronic tools when appropriate, as they can improve communication.
- Make good use of the 24- to 48-hour follow-up call to confirm instructions, see how everything is going, make sure the prescriptions were picked up, determine whether there have been any side effects, and ask whether any old medications are still being taken.
- When dealing with a caregiver during the follow-up call, check the accuracy of the patient’s medication list. Make sure the patient is taking the medication as prescribed, and see how it is being tolerated.
- Ensure that the patient has a primary care doctor who is aware of the situation, and that a primary care appointment is scheduled within seven to 14 days following hospitalization.
- Use health coaching to help patients successfully transition. Many times, this does not involve skilled nursing; instead, it concentrates on coordinating the logistics of transportation, medical equipment, and prescriptions. In some cases, it may be necessary to go to the patient’s home to determine whether the environment is contributing to health risks and to ensure that medications are being taken properly.
The days of assuming a hospital’s responsibility ends when a patient leaves are over. Now, it is recognized that the hospital plays a role in a patient’s long-term successful recovery. Hospitals must strive to decrease the chance of complications and readmissions while also being aware of the liability risks that can result when negligent communication practices contribute to patient harm. Healthcare providers and caregivers need to work together to achieve optimal health outcomes.
Lisa Simm, RD, MBA, CPHQ, CPPS, CPHRM, FASHRM, is manager of risk management at Coverys. Ann Fiala, RN, BSN, CPHRM, CHC, is senior risk specialist at Coverys.