Home / For Your Practice / Safety / ISMP – From the Hospital to Long-term Care: Protecting Vulnerable Patients during Handoffs

ISMP – From the Hospital to Long-term Care: Protecting Vulnerable Patients during Handoffs

Jul 28, 2013
Problem: More than 3 million Americans will rely on services provided by long-term care (LTC) facilities at some point during 2013, and more than 1.4 million will live in the nearly 16,000 LTC facilities on any given day.1 About one-third of these residents will take an average of nine medications daily.2 The volume of medications places residents at risk for medication errors, particularly during transitions from a hospital into a LTC facility.3,4

If you don’t work in a LTC facility, you may be asking, “What does this have to do with me?”….

First and foremost, medication errors that occur during transitions from a hospital to a LTC facility often originate in the hospital.1-7 Lapses in communication between facility staff along with documentation and transcription errors3 have led to poor coordination of care. Studies have shown that discharge summaries and transfer/referral forms do not match for more than half 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 omission of prn medications that should have been continued, 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 discharge from a 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, which included copies of the inpatient medication administration record (MAR), orders, progress notes, discharge summary, and 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/mL, was listed on the MAR immediately after the drug name. The nurse expected the patient’s dose to be listed after the drug name, so she mistakenly listed the insulin dose as 100 units/mL when she copied the most current medications from the MAR. She then called the patient’s LTC physician to request admission orders. Because the physician had followed the patient’s course of hospitalization, 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 to be filled. Despite the high insulin dose, the pharmacy processed the order as 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 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 daunting task of reconciling potentially conflicting or absent information from hospitals, many LTC facilities 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, 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.

Safe Practice Recommendations: Numerous opportunities exist to improve the communication of accurate and appropriate medication therapy when a patient is discharged to a LTC facility. Consider the following recommendations to improve medication safety during these vulnerable transitions in care.

Establish a list. Prepare a list of medications that might be accidentally continued but not needed after hospitalization (e.g., pain medications, benzodiazepines, sleeping aids, electrolyte supplements, gastrointestinal agents, proton pump inhibitors).7 Share the list with prescribers and other clinicians who review the records that are forwarded to LTC facilities. Refer to the list during discharge medication reconciliation to identify potential discrepancies that may require clarification. Remind staff that some of the drugs on the list may also be accidentally omitted when needed (e.g., stool softener if the patient is taking a narcotic analgesic).

Verify accuracy of discharge summaries. Require prescribers to verify dictation and transcription of discharge summaries, and to ensure that the medication information contained in the summary is correct at the time of discharge. Changing the clinical workflow to coordinate the completion of the patient transfer/referral form with the discharge summary can enhance their consistency.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 cautions, and when the last dose was administered. However, it is also important for physicians to specify which drugs are being discontinued after discharge, and to include the reasons for any discontinued drugs or changes to previous medications that the patient was taking prior to hospitalization.6,12

Conduct medication reconciliation. For patients discharged to a LTC facility, a nurse, pharmacist, or other qualified professional should review the drugs prescribed upon discharge and compare them to the medications the patient was taking in the hospital and at home. 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) during the reconciliation process. After reviewing the prescribed medications and noting discrepancies, call the prescriber to discuss any discrepancies found while reconciling the medications, ask whether medications typically used only during hospitalization should be continued, verify medications that were not continued after discharge. Also verify the doses of medications that often require dose adjustments, such as 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).

Involve pharmacy. Have pharmacists review the list of medications prescribed for patients who are being transferred to LTC facilities to help identify omitted or indicated medications and dosing errors. If staffing does not permit pharmacy review of all LTC transfers, establish an automatic consultation to pharmacy for patients being discharged on drugs known to be involved in transition errors (Table 1).

Standardize accompanying documents. Determine the documents that must accompany transfer/referral documents for LTC patients. Require a clinician to review the accompanying documents to ensure completeness and clarity prior to transfer.

Provide 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 to allow the LTC staff to begin the medication reconciliation process and to help ensure that required medications are available as soon as possible. However, experts advise not to prepare a discharge summary more than a few hours before discharge to ensure 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 LORazapam). A phone conversation between the discharging physician and LTC physician is also recommended for complex patients.

Solicit feedback from LTC facilities. Ask staff at frequently referred LTC facilities, to report any discrepancies identified in discharge orders, transfer/referral forms, MARS, and prescriptions, so you can improve the processes associated with coordinating and communicating each patient’s plan of care during transitions. Regularly scheduled meetings with nursing administration, social services, consultant pharmacists, and the medical director of commonly used LTC facilities would also be helpful in opening lines of communication and soliciting the feedback necessary for improvement.

  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. www.ismp.org/sc?id=212
  2. Handler SM, Wright RM, Ruby CM, et al. Epidemiology of medication-related adverse events in nursing homes. Am J Geriatr Pharmacother. 2006;4(3):264–72.
  3. Desai R, Williams CE, Breene SB, et al. 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, et al. 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, Field TS, 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, et al. 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, et al. 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, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:2002-12.
  12. Bergkvist A, Midlov P, Hoglund P, et al. Improved quality in the hospital discharge summary reduces medication errors—LIMM: Landskrona Integrated Medicine Management. Eur J Pharmacol. 2009;65(10):1037-46.

Table 1. Medications most often involved in errors during transition to a nursing home.


Common Error Type(s) During Transition

Communication error regarding dose, failure to order INR
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
Dosing errors and delays in administration
Dosing errors
Dosing errors or accidental discontinuation
Omissions or accidental continuation of a drug used during acute illness but no longer needed
Name confusion with ALPRAZolam
Name confusion with LORazepam
Dosing errors
Dosing errors
Dosing errors, and patches not removed and properly discarded before application of new patch
Name confusion with esomeprazole, and accidental continuation of a drug used during acute illness but no longer needed
Name confusion with omeprazole, and accidental continuation of drug used during acute illness but no longer needed
Dosing errors and name confusion with methadone, mix-ups between regular strength and concentrated oral solutions
Distractions and name confusion with morphine leading to transcription errors
Transcription errors (unspecified) and dosing errors
Transcription errors (unspecified)
other gastrointestinal agents6 (e.g., laxatives, stool softners, antidiarrheals, antiemetics) Omissions or accidental continuation of a drug used during acute illness but no longer needed

Errata. In our July 11 Safety Brief about a ketamine dosing error, we erroneously stated that the label of ketamine injection 50 mg per mL and 100 mg per mL carries a warning that it must be further diluted prior to IV use. It is only the 100 mg per mL strength that carries such a warning. We apologize for the error and any confusion it caused to our readers.

Courtesy of ISMP.org


Diabetes in Control would like to acknowledge the Institute for Safe Medication Practices’ outstanding work in medication safety, including the above excerpt.

Report Medication Errors to ISMP:

Diabetes in Control is partnered with the Institute for Safe Medication Practices (ISMP) to help ensure errors and near-miss events get reported and shared with millions of health care practitioners. The ISMP is a Patient Safety Organization obligated by law to maintain the anonymity of anyone involved, as well as omitting or changing contextual details for that purpose. Help save lives and protect patients and colleagues by confidentially reporting errors to the ISMP.



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