From the hospital to long-term care: Protecting vulnerable patients during transitions of

As seen in the Consultant Connection September 2014 Issue
Source: NurseAdviseERR July 2014

More than 3 million Americans will rely on services provided by long-term care (LTC) facilities during the year, and greater than 1.4 million will live in the nearly 16,000 LTC facilities on any given day.  Approximately one-third of these residents will take an average of nine medications daily, significantly increasing the risk of medication errors, particularly during the transition from a hospital to a LTC facility.2-4
Medication errors that occur during transition from a hospital to a LTC facility often originate in the hospital.1-7 Lapses in communication among facility staff along with documentation and transcription errors3 have led to poor coordination of care. Studies have demonstrated that information on discharge summaries and transfer/referral forms do not match for more than 50% of LTC admissions, with at least one medication discrepancy in 70% of all admissions.3,5,6 Add to this the accidental continuation of medications intended for administration only while the patient was hospitalized,7 along with the omission of as needed  (prn)  medications that  should have been continued. Thus, it is not surprising that error rates of 21% or more have been reported during transitions between hospitals and LTC facilities.3,6,7 Up to 60% of these errors have been serious, life-threatening, or fatal,8 as in the following example.
After being discharged from the hospital, a patient was transferred to a LTC facility. During the initial assessment of the patient at the LTC facility, the receiving nurse reviewed the transfer information faxed to the facility. This information included copies of the inpatient medication administration record (MAR), orders, progress notes, discharge summary, and the referral/transfer form. The orders and progress notes included the most recent morning and evening insulin doses. However, the referral/transfer form, discharge summary, and MAR did not specify the insulin doses, although the concentration of insulin, 100 units per mL, was listed on the MAR immediately after the drug name. The LTC nurse referred to the MAR and mistakenly listed the insulin dose as 100 units when she copied the most current medications. The nurse then contacted the patient’s LTC physician who had followed the patient’s course of hospitalization, and he instructed the nurse to “continue the same orders.” The nurse transcribed the list of medications onto an order form and sent it to the pharmacy where the order was filled despite the unusually high insulin dose (100 units in the morning and evening).The patient received one dose of 100 units and experienced severe hypoglycemia. The patient was transferred back to the hospital but died a short time after arrival.4
As demonstrated with this error, poor communication across care settings and mistakes during order transcription are the most frequent causes of medication errors during transitions from hospitals to LTC facilities.3 More than half of these errors originated during the initial documentation of the medication therapy upon admission to the LTC facility. When a patient is newly admitted to a LTC facility, medication orders are typically reviewed by a nurse and verified on the telephone by a LTC physician who may be unfamiliar with the patient. LTC facilities rely on the hospital discharge summaries, prescriber-signed transfer/referral forms, and other documents sent from the hospital to communicate prior drug therapy to the admitting LTC physician. Given the task of reconciling potentially conflicting or absent information from hospitals, LTC facilities may struggle with the medication reconciliation process.3,6,7 It may  take up to 48 hours  for  the LTC physician to evaluate the patient in person. During this time period, new admissions are particularly vulnerable to medication errors.
Errors involved in transitions from the hospital to a LTC facility may be more likely to cause resident harm because they often involve high-alert medications.3,6,8-10 Warfarin, insulin, opioids, and cardiovascular medications top the list of drugs most frequently involved in harmful errors during transitions.3,9 Table 1 provides additional medications commonly involved in errors  during transitions between the hospital and LTC facility. These medications have also caused frequent emergency department visits among elderly patients.11 Errors during transitions are more likely to  involve the wrong dose or the wrong drug, particularly drugs with look-alike names or those that require dose adjustments (e.g., warfarin).3
Medication errors that originate during transition from a hospital to a LTC facility have also led to preventable readmissions to the hospital.3,5-8 Patients or residents with medication discrepancies on their health record  have a higher rate (14.2%) of 30-day readmissions than patients without medication discrepancies (6.1%).11 Hospitals have an additional incentive to prevent readmissions now that financial penalties are being levied by the Centers for Medicare & Medicaid (CMS) against hospitals with high readmission rates for targeted conditions.
Numerous opportunities exist to improve the communication of accurate and appropriate medication therapy when patients transition to a LTC facility. To improve medication safety during these vulnerable transitions in care, consider the recommendations listed in the “Recommendations” section at the end of this article on page 3.

Table 1:

Medication Common Error Type(s) During Transition
warfarin3,6,8,9,10 Communication error regarding dose, failure to order INR
insulin3,6,9 Communication error regarding dose
oxyCODONE with acetaminophen3,6,9,10 Name confusion with HYDROcodone with acetaminophen
HYDROcodone with acetaminophen3,6,9,10 Name  confusion  with oxyCODONE with acetaminophen
enoxaparin3,6,8 Dosing errors and delays in administration
furosemide3,6,8,9,10 Dosing errors
metoprolol3,6 Dosing errors or accidental discontinuation
potassium3,6,9,10 Omissions or accidental continuation of a drug used during acute illness but no longer needed
LORazepam3,9,10 Name confusion with ALPRAZolam
ALPRAZolam3,9,10 Name confusion with LORazepam
aspirin3,6 Dosing errors
acetaminophen3,6 Dosing errors
fentaNYL3,6,9,10 Dosing errors, and patches not removed and properly discarded before application of new patch
omeprazole3,6,10 Name confusion with esomeprazole, and accidental continuation of a drug used during acute illness but no longer needed
esomeprazole6,10 Name confusion with omeprazole, and accidental continuation of drug used during acute illness but no longer needed
morphine6,9,10 Dosing errors and name confusion with methadone, mix-ups between regular strength and concentrated oral solutions
methadone6,10 Distractions and name confusion with morphine leading to transcription errors
risperiDONE6,8,10 Transcription errors (unspecified) and dosing errors
nitrofurantoin6,10 Transcription errors (unspecified)
other gastrointestinal agents6 (e.g., laxatives, stool softeners, antidiarrheals, antiemetics) Omissions or accidental continuation of a drug used during acute illness but no longer needed


Recommendations To improve medication safety during transfers from hospital to LTC facility

  • Establish a list. Prepare a generic list of medication categories that are generally not continued after hospitalization (e.g., pain medications, benzodiazepines, sleeping aids, electrolyte supplements, gastrointestinal agents, proton pump inhibitors).7 Refer to the list during medication reconciliation to identify potential discrepancies that may require clarification.
  • Do not write “continue orders” on discharge summaries. Discharge summaries/transfer forms or verbal orders to the LTC facility should not simply state “continue” or “resume” the same medications prescribed during hospitalization or as listed. Prescribers should provide a new, complete order for each medication.
  • Verify accuracy of discharge summaries. Require prescribers to cosign (verify) the dictation and transcription of discharge summaries, and to ensure that the medication information contained in the summary is correct at the time of discharge and devoid of potentially confusing abbreviations.6
  • Provide reasons for changes. Most hospitals utilize a structured LTC transfer/referral document to assist with communication of medication lists. These documents/templates often prompt prescribers to include a complete order for each medication, as well as its purpose, whether it’s a new or changed medication (dose/frequency), any special precautions, and when the last dose was administered. It is also important for physicians to specify which drugs are being discontinued after discharge, the reason for discontinuation, and any changes to previous medications that the patient was taking prior to hospitalization.6,12
  • Conduct medication reconciliation for readmissions. Review the drugs prescribed upon hospital discharge and compare them to the medications the patient was taking in the hospital and prior to hospitalization. Make note of any discrepancies, including newly prescribed drugs, potential omissions without an explanation, or differences in a prescribed drug’s form (e.g., extended release versus immediate release), dose, frequency of administration, or route of administration. Pay particular attention to the drugs most often involved in transition errors (Table 1, on page 2) during the reconciliation process. After reviewing the prescribed medications, contact the prescriber to discuss any discrepancies found, and clarify the continuation/discontinuation of hospital medications. Also verify the doses of medications that often require dose adjustments, such as with insulin and warfarin, and ask about the frequency of special testing (e.g., blood glucose testing) and other laboratory studies (e.g., INR, including the desired targeted range for monitoring).
  • Standardize accompanying documents. Determine which documents must accompany transfer/referral documents for LTC patients. Require a clinician to review the accompanying documents to ensure completeness and clarity prior to transfer.
  • Obtain information early. When possible, design a system in which the patient’s transfer information is provided to the LTC facility several hours before the patient arrives. This allows the LTC staff to begin the medication reconciliation process and helps ensure that required medications are available as soon as possible. However, experts advise not to prepare a discharge summary more than a few hours prior to transfer to make certain the document is up-to-date.3,6 For patients with complex care needs, a phone conversation between the hospital primary care nurse and a LTC facility nurse is highly recommended. When discussing medication orders, spell- look- and sound-alike drug names that are often confused (e.g., ALPRAZolam and LOR-azepam). A phone conversation between the discharging physician and LTC physician is also recommended for complex patients.
  1. Department of Health and Human Services, Centers for Medicare & Medicaid Services. CMS 2012 nursing home plan. Action plan for further improvement of nursing home quality.
  2. Handler SM, Wright RM, Ruby CM, Hanlon JT. Epidemiology of medication-related adverse events in nursing homes. Am J Geriatr Pharmacother. 2006;4(3):264–72.
  3. Desai R, Williams CE, Greene SB, Pierson S, Hansen RA. Medication errors during patient transitions into nursing homes: characteristics and association  with patient harm. Am J Geriatr Pharmacother. 2011;9(6):413-22.
  4. ISMP Canada. Medication incidents occurring in long-term care. ISMP Canada Safety Bulletin.2010;10(9):1-3.
  5. Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004;141(7):533–6.
  6. Tija J, Bonner A, Briesacher BA, McGee S,Terrill E, Miller  K. Medication discrepancies  upon hospital to skilled nursing facility  transitions. J Gen  Intern Med. 2009;24(5):630-5.
  7. Truax BT. Medication errors in long-term care. Patient Safety Tip of the Week.  Patient Safety Solutions. July 21, 2009.
  8. Gurwitz JH, FieldTS, Avorn J, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med. 2000;109(2):87–94.
  9. Greene SB, Williams CE, Pierson S, Hansen RA, CareyTS. Medication error reporting in nursing homes: identifying targets for patient safety improvement. Qual Saf Health Care. 2010;19:218-22.
  10. Hansen RA, Cornell PT, Ryan PB, Williams CE, Pierson S, Greene SB. Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality  improvement opportunities. Pharmacoepidemiol Drug  Safety. 2010;19(10):1087-94.
  11. Budnitz DS, Lovegrove  MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans.  N Engl J Med. 2011;365:2002-12.
  12. Bergkvist A, Midlov P, Hoglund P, Larsson l, Bondesson A, ErikssonT. Improved quality  in the hospital discharge summary reduces medication errors—LIMM: Landskrona Integrated  Medicine  Management. Eur J Pharmacol. 2009;65(10):1037-46.
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