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Running head: IMPROVING DISCHARGE 1

IMPROVING DISCHARGE 6

Improving Hospital Discharge through Medication Reconciliation and Education

Chamberlain University

NR- Evidence Based Practice

January 2020

The topic that my group was assigned was Improving Hospital Discharge through Medication Reconciliation and Education. With nurses caring for such a wide variety of populations, there are bound to be some sort of medical barriers to arise. This could be in the form of language or cultural barriers, social isolation, and even attitudes of health care personnel towards patients of low socioeconomic status. Whatever it may be, there needs to be improvement upon being discharged to improve the overall quality of care to the patient, lower readmissions rates and to help lower cost of care.

Clinical Question

The transition from a health facility to home is an intricate and susceptible period for most patients. This is due to the ineffective hospital discharge that most patients go through. Poor organization and inefficient discharge planning lead to increased cases of readmissions, increased cost of care, patient injuries, adverse effects (AEs) and patient dissatisfaction. Also, poor medical reconciliation is the main cause of medication errors and can follow a patient during her hospital stay.

Studies have revealed that around 20% of all medical patients are faced with an adverse effect within 35 days of hospital discharge. The least common AEs are incorrect medication prescription and the most common AEs are adverse drug events which constitute over 60 %. Poor communication between the patient and the health practitioner is the major cause of many AEs (Sherman, 2016). Of the three heart failure patients, one is likely to be readmitted within 30 days after being recharged from a hospital. In 2011, a study showed that 32 percent of 564 discharged patients had laboratory tests that were not conducted. Of the 32 percent, only 11 percent of the patients had documentation of their pending tests. Readmissions that happen within 1 month of discharge cost the United States healthcare system an average of $ 15 billion each year (Hennen & Jorgenson, 2014).

The PICOT question

Do effective medication reconciliation and education to patients about the need to take their medicines on time and as scheduled, compared to ordinary practice (ineffective medication reconciliation and no education to patients on the importance of sticking to the schedule when taking medication), lead to an improved hospital discharge process and reduced cases of readmissions, satisfied patients within 1 month for adult patients?

Population (P):
Discharged adult patients

Intervention (I):
Effective medication reconciliation and education to patients about the need to take their medicines on time and as scheduled.

Comparison (C):
ordinary practice- medication reconciliation and no education to patients on the importance of sticking to the schedule when taking medication.

Outcomes (O):
Patient satisfaction, reduced cases of readmissions, improved process of hospital discharge.

Time (T):
Within 1 month after discharge.

Purpose of your paper

The purpose of this paper is to show how medication reconciliation, effective discharge planning and education to patients about the need to take their medicines on time and as scheduled is crucial in improving the process of hospital discharge for patients, reducing cases of patient readmitting, reducing injuries to patients and cases of AEs and also how this can save the overall cost of treating the readmitted patients.

Levels of Evidence

The type of question asked is a Prognosis question. This is because it determines a course over a given time (medication reconciliation, effective discharge planning and education to patients) and a guess to the expected outcomes (reduced cases of patient readmitting, reducing injuries to patients, and an improved process of discharging patients)

The above question can be answered better by a Cohort and Case-control studies because it involves following up a group of discharged patients after medication reconciliation and an effective discharge planning and education to them, and note down the outcomes comparing them with the expected results.

Search strategy

The databases used are the Chamberlain library, Medline, PubMed, and Google Scholar. This was achieved by turning the PICOT framework into a clinical research topic. An example of a clinical research topic is “Medication reconciliation and Education as a method of improving hospital discharge”. The search terms from such a topic include: Medication Reconciliation, Educating patients, and improving hospital discharge. Also, I combined Population (P) and Intervention (I) to get another search topic: adult patients and effective medication reconciliation.

Using my search terms and topics resulted in so many articles and in order to save time and get the best and appropriate articles, I did put limits on my search. The databases I used gave me an option to put limits on my searches and the ones are used include type of article (reviews), age (adults) and Language (English). The two chosen articles include: “An initiative to Improve Patient Education by Clinical Nurses” by Jessica R. Sherman “Improving handoff communication from hospital to home: the development, implementation, and evaluation of a personalized patient discharge letter” Bianca M. Buurman, Kim J. Verhaegh, Marian Smeulers, Hester Vermeulen, Susanne E. Geerlings, Susanne Smorenburg, and Sophia E. de Rooij

These two articles were selected because they have quality and relevant answers to the questions at hand. The articles had a manageable number of pages to read and hence no time can be wasted when looking for the evidence and answers. The two articles are also broad enough in that the information they provide can also be used later in my studies and also for my personal experience.

Conclusion

A considerable effort was made to refine the search terms so as to come up with the best articles to be used in the next assignment. The above two articles contain the required quality to answer the questions and also equip the reader with relevant information that can be used in the field.

References

Buurman, B. M., Verhaegh, K. J., Smeulers, M., Vermeulen, H., Geerlings, S. E., Smorenburg, S., & Rooij, S. E. D. (2016). Improving handoff communication from hospital to home: the development, implementation and evaluation of a personalized patient discharge letter. International Journal for Quality in Health Care, 28(3), 384–390. doi: 10.1093/intqhc/mzw046

Hennen C.R and Jorgenson A. (2014) “Importance of Medication Reconciliation in the Continuum of Care” 14: pg. 1-3

Sherman, J. R. (2016). An initiative to improve patient education by clinical nurses. Medsurg Nursing, 25(5), 297.

NR449 Evidence Based Practice

Required Uniform Assignment: Analyzing Published Research
Purpose

The purpose of this paper is to interpret the two articles identified as most important to the group topic.

COURSE OUTCOMES

This assignment enables the student to meet the following course outcomes:
CO 2: Apply research principles to the interpretation of the content of published research studies. (POs #4
and #8)

CO 4: Evaluate published nursing research for credibility and clinical significance related to evidence- based
practice. (POs #4 and #8)

DUE DATE

Refer to the course calendar for due date information. The college’s Late Assignment policy applies to this
activity.

TOTAL POINTS POSSIBLE: 200 POINTS REQUIREMENTS

The paper will include the following.

1. Clinical question
a. Description of problem
b. Significance of problem
c. Purpose of paper

2. Description of findings
a. Summarize basics in the Matrix Table as found in Assignment Documents in e-College.
b. Describe

i. Concepts
ii. Methods used
iii. Participants
iv. Instruments including reliability and validity
v. Answer to “Purpose” question vi. Identify next step for group

3. Conclusion of paper
4. Format

a. Correct grammar and spelling
b. Use of headings for each section

NR449 Evidence Based Practice
c. Use of APA format (sixth edition)
d. Page length: three pages

PREPARING THE PAPER

1. Please make sure you do not duplicate articles within your group.
2. Paper should include a title page and a reference page.

DIRECTIONS AND ASSIGNMENT CRITERIA

Assignment
Criteria

Points % Description

Clinical Question

15%

1. Problem is described: What is the focus of your group’s work?
2. Significance of the problem is described: What health outcomes result

from your problem? Or what statistics document this is a problem? You
may find support on websites for government or professional
organizations.

3. Purpose of your paper: What will your paper do or describe? “The purpose
of this paper is to . . .”

**Please note that although most of these questions are the same as
you addressed in paper 1, the purpose of this paper is different. You
can use your work from paper 1 for items 1 and 2 above, including
any suggestions for improvement provided as feedback. Item 3 above
should be specific to this paper.

Description of
Findings: Summary

30%

Summarize the basics of each article in a matrix table that appears in the
appendix.

Description of
Findings:

Description
60 30%

Describe in the body of the paper the following.
• What concepts have been studied?
• What methods have been

used?

• Who are the participants or members of the samples?
• What instruments have been used? Did the authors describe the

reliability and validity?
• How do you answer your original “purpose of this paper” question?

Do the findings of the articles provide evidence for your answers? If
so, how? If not, what is still needed to be able to answer your
question?

• What is needed for the next step? Identify two questions that can
help guide the group’s work.

Description of
Findings: Conclusion 20 10%

Conclusion: Review major findings in your paper in a summary paragraph.

Format 30

15%

1. Correct grammar and spelling
2. Use headings for each section: Problem, Synthesis of the Literature

(Concepts, Methods, Participants, Instruments, Implications for Future
Work), Conclusion.

3. APA format (sixth ed.): Appendices follow references.
4. Paper length: Three pages

Total 200 100%

NR449 RUA Analyzing Published Research x Revised 07 / 25 /2016 2

NR449 Evidence Based Practice

NR449 RUA A nalyzing Published Research x Revised 07/25 /2016 4

GRADING RUBRIC

Assignment
Criteria

Outstanding or Highest
Level of Performance

A (92–100%)

Very Good or High Level of
Performance

B (84–91%)

Competent or Satisfactory
Level of Performance

C (76–83%)

Poor, Failing or
Unsatisfactory Level of

Performance F
(0–75%)

Clinical Question
(30 points)

Includes all elements in a
manner that is clearly
understood.

• Problem description
provides focus of the
group’s work.

• Significance of the problem
is clearly stated and
supported by current
evidence.

• Purpose of paper is clearly
stated.

28-30

points

Missing only one element

OR
One element is not presented
clearly

• Problem description provides
focus of the group’s work.

• Significance of the problem is
clearly stated and supported
by current evidence.

• Purpose of paper is clearly
stated.

26-27 points

Missing two elements

OR
One element is not presented
clearly
• Problem description provides
focus of the group’s work.
• Significance of the problem is
clearly stated and supported
by current evidence.
• Purpose of paper is clearly
stated.

23-25 points

Missing two or more elements

AND/OR
One or more elements are not
presented clearly

• Problem description provides
focus of the group’s work.
• Significance of the problem is
clearly stated and supported
by current evidence.
• Purpose of paper is clearly
stated.

0-22 points

Description of
Findings:
Summary
(60 points)

Summary omits no
more than one required
item from the Evidence
Matrix Table.

55-60 points

Summary omits two or three
required items from the
Evidence Matrix Table.

51-55 points

Summary omits four required
items from the Evidence
Matrix Table.

46-50
points

Summary omits five or more
required items from the
Evidence Matrix Table.

0–45

points

NR449 Evidence Based Practice

NR449 RUA A nalyzing Published Research x Revised 07/25 /2016 5

Description of
Findings:
Description
(60 points)

Description includes ALL
elements.

• What concepts have
been studied?

• What methods have
been used?

Description missing no more than
one element.

• What concepts have been

studied?
• What methods have been

used?

Description missing no more than
two elements.

• What concepts have been
studied?
• What methods have been
used?

Description missing three or
more elements.

• What concepts have been
studied?
• What methods have been
used?

NR449 Evidence Based Practice

NR449 RUA A nalyzing Published Research x Revised 07/25 /2016 6

• Who are the
participants or
members of the
samples?

• What instruments
have been used?
Did the authors
describe the
reliability and
validity?

• How do you answer
your original “the
purpose of this
paper” question?
Do the findings of
the articles provide
evidence for your
answers? If so,
how? If not, what is
still needed to be
able to answer your
question?

• What is needed for
the next step?
Identify two
questions that can
help guide the
group’s work.

56–60 points

• Who are the participants or
members of the samples?

• What instruments have
been used? Did the authors
describe the reliability and
validity?

• How do you answer your
original “the purpose of
this paper” question? Do
the findings of the articles
provide evidence for your
answers? If so, how? If not,
what is still needed to be
able to answer your
question?

• What is needed for the
next step? Identify two
questions that can help
guide the group’s work.

51–55 points

• Who are the participants or
members of the samples?
• What instruments have
been used? Did the authors
describe the reliability and
validity?
• How do you answer your
original “the purpose of
this paper” question? Do
the findings of the articles
provide evidence for your
answers? If so, how? If not,
what is still needed to be
able to answer your
question?
• What is needed for the
next step? Identify two
questions that can help
guide the group’s work.

46–50 points

0–45 points

NR449 Evidence Based Practice

NR449 RUA A nalyzing Published Research x Revised 07/25 /2016 7

Description of
Findings:
Conclusion
(20 points)

Summary paragraph includes
ALL major findings from
article.

• Independently extracts

complex data from a
variety of quantitative
sources, presents those
data in summary form,
makes appropriate

Summary paragraph omits ONE
major finding from article.

• Independently extracts complex

data from a variety of
quantitative sources, presents
those data in summary form,
makes appropriate
connections and inferences
consistent with the data, and

Summary paragraph omits TWO
major findings from article.

• Independently extracts complex
data from a variety of
quantitative sources, presents
those data in summary form,
makes appropriate
connections and inferences
consistent with the data, and

Summary paragraph omits THREE
or MORE major findings from
article.

• Independently extracts complex

data from a variety of
quantitative sources, presents
those data in summary form,
makes appropriate
connections and inferences

connections and inferences

consistent with the data, and
relates them to a larger
context.

• Recognizes points of view
and value assumptions in
formulating
interpretation of data
collected and articulates
the point of view in a
given situation.

• Identifies
misrepresentations in the
presentation points of
quantitative data and the
logical and empirical
fallacies in inferences
drawn from data.
19-20 points

relates them to a larger context.
• Recognizes points of view and

value assumptions in
formulating interpretation of
data collected and articulates
the point of view in a given
situation.

• Identifies misrepresentations in
the presentation of
quantitative data and the
logical and empirical fallacies in
inferences drawn from data.

17-18 points

relates them to a larger context.
• Recognizes points of view and
value assumptions in
formulating interpretation of
data collected and articulates
the point of view in a given
situation.
• Identifies misrepresentations in
the presentation of
quantitative data and the
logical and empirical fallacies in
inferences drawn from data.

16 points

consistent with the data, and
relates them to a larger
context.

• Recognizes points of view and
value assumptions in
formulating interpretation of
data collected and articulates
the point of view in a given
situation.

• Identifies misrepresentations in
the presentation of quantitative
data and the logical and
empirical fallacies in inferences
drawn from data.

0-15 points

NR449 Evidence Based Practice

NR449 RUA A nalyzing Published Research x Revised 07/25 /2016 8

Grammar, Spelling,
Mechanics, and
APA Format
(30 points)

• Length is three full
pages.

• Used appropriate APA

format and is free of
errors.

• Includes ALL headings

and subheadings as
instructed.

• Grammar, spelling, and
mechanics are free of
errors.

28–30 points

• Length is no more than
one quarter page under or
over.

• Used appropriate APA
format, with one type of
error.

• Includes ALL headings and

subheadings as instructed.
• Grammar, spelling, and

mechanics have one type
of error.

26–27 points

• Length is no more than one
half page under or over.

• Used appropriate APA
format, with two types of
errors.

• Includes ALL headings and
subheadings as instructed.
• Grammar, spelling, and

mechanics have two types
of errors.

23–25 points

• Length is three quarters of a
page or more under or over.

• Attempts made to use APA
format; three or more types
of errors are present.

• Includes ALL headings and
subheadings as instructed.

• Grammar, spelling, and
mechanics have three or
more types of errors.

0–22 points

Total Points Possible = 200 points

Chamberlain College of Nursing NR449 Evidence-Based Practice

Evidence Matrix Table

Article

Reference

Purpose

Hypothesis

Study Question

Variables

Independent(I)

Dependent(D)

Study Design

Sample

Size and Selection

Data Collection

Methods

Major Findings

1
(sample not a real article)

Smith, Lewis (2013),
What should I eat? A focus for those living with diabetes. Journal of Nursing Education, 1 (4) 111-112.

How do educational support groups effect dietary modifications in patients with diabetes?

D-Dietary modifications
I-Education

Qualitative

N- 18
Convenience sample-selected from local support group in Pittsburgh, PA

Focus Groups

Support and education improved compliance with dietary modifications.

NR449 Evidence Matric Table x Revised10/20/14 ns/cs

PRACTICE REPORTS Medication reconciliatio

404 Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

JOAN S. KRAMER, PHARM.D., is Clinical Research and Hospital Medi-
cine Specialist, Department of Pharmacy; PAULA J. HOPKINS, B.S.N.,

M.S.N., is Adult Medical–Surgical Clinical Nurse Specialist, Depart-
ment of Trauma and Surgery; and JAMES C. ROSENDALE is Data
Architect, Department of Pharmacy, Wesley Medical Center (WMC),
Wichita, KS. JAMES C. GARRELTS, B.S., PHARM.D., is Leader, Clinical
Pharmacy Services, Via Christi Regional Medical Center, St. Francis
Campus, Wichita; at the time of this study he was Manager, Critical
Care Pharmacy Services and Research, Department of Pharmacy,
WMC. LADONNA S. HALE, PHARM.D., is Associate Professor, Depart-
ment of Physician Assistant, College of Health Professions, Wichita
State University, Wichita, and Clinical Pharmacist, Department of
Pharmacy, WMC. TINA M. NESTER, PHARM.D., is Internal Medicine
Clinical Specialist, Department of Pharmacy; PATTY COCHRAN,

B.S.N., M.S.N., is Clinical Nurse Specialist—Acute Care for the El-
derly, Department of Nursing; and LESLIE A. EIDEM, B.S., is Pharmacy
Manager, Pediatric/Women’s Services and Medication Safety, Depart-
ment of Pharmacy, WMC. ROBERT D. HANEKE, B.S., PHARM.D., is
National Clinical Director, PharmaSource Healthcare, Inc., Sylvia,
KS; at the time of this study he was Ambulatory and Geriatrics Clini-
cal Specialist, Department of Pharmacy, WMC.

Address correspondence to Dr. Kramer at the Department of
Pharmacy, Wesley Medical Center, 550 North Hillside, Wichita, KS
67214-4976 (joan.kramer@wesleymc.com).

DOI 10.2146/ajhp060506

Implementation of an electronic system
for medication reconciliation

JOAN S. KRAMER, PAULA J. HOPKINS, JAMES C. ROSENDALE, JAMES C. GARRELTS, LADONNA S. HALE,
TINA M. NESTER, PATTY COCHRAN, LESLIE A. EIDEM, AND ROBERT D. HANEKE

Purpos

The feasibility of implement-
ing an electronic system for targeted
pharmacist- and nurse-conducted admis-
sion and discharge medication reconcilia-
tion and its eff ects on patient safety, cost,
and satisfaction among providers and
nurses were studied.
Methods. This study was conducted in two
phases: a preimplementation phase and a
postimplementation phase. In the preim-
plementation phase, admission medication
histories and discharge medication coun-
seling followed standard care processes.
During postimplementation, pharmacists
and nurses collaborated to electronically
complete admission and discharge medi-
cation reconciliation documentation. Four
reports were developed for medication rec-
onciliation documentation: (1) home medi-
cation profi le report, (2) home medication
reconciliation report, (3) discharge medica-
tion reconciliation report, and (4) patient
discharge medication report. Patients were
contacted after discharge to measure their
satisfaction with the medication counsel-
ing and medication instructions received.
Health care providers completed a survey
indicating their satisfaction with the elec-
tronic medication reconciliation processes.
Results. A total of 283 patients were includ-

ed in the study. Patients in the postimple-
mentation group took signifi cantly more
prescription and nonprescription medica-
tions, and their total number of medica-
tions signifi cantly exceeded the number
taken by the preimplementation group.
Pharmacists completed signifi cantly more
dosage changes in the postimplementa-
tion phase than in the preimplementation
phase. In the preimplementation phase,
nurses identifi ed more incomplete medica-
tion orders, dosage changes, and allergies
than they did in the postimplementation
phase. Patients in the postimplementation
group reported a higher level of agreement
on all survey items regarding adequate
discharge medication instructions.
Conclusion. Patients who had their medi-
cations electronically reconciled reported a
greater understanding of the medications
they were to take after discharge from the
hospital, including medication administra-
tion instructions and potential adverse
eff ects.

Index terms: Computers; Documentation;
Dosage; Errors, medication; Hospitals;
Nurses; Patient information; Patient infor-
mation; Pharmacists; Toxicit

Am J Health-Syst Pharm. 2007; 64:404-22

A
n estimated 5% of hospitalized
patients experience medication
errors, 60% of which occur

during transitions of care (i.e., ad-
mission, transfer between levels of
care, and discharge).1 In the United
States, this translates to over 90,000
hospitalized patients who experience
medication errors each year.2

Two critical times to prevent med-
ication errors are at admission and
discharge.1,2 Adverse drug events are
responsible for 3.2–9.6% of hospital
admissions and are the fi fth leading
cause of death in the United States.3-15
Recording an accurate and complete
medication history is an important
part of the initial patient assessment
at admission. Inaccuracies in the
medication history result in wasted
time and interrupted or inappropri-
ate drug therapy and may jeopardize
patient safety.1,16-24 Nonprescription
medications and herbal preparations
are also associated with clinically
significant drug interactions and
adverse effects.25,26 In a Finnish study
of nonprescription and prescription

PRACTICE REPORTS Medication reconciliati

405Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

drug interactions, 4% of adults tak-
ing nonprescription products were
exposed to potentially clinically sig-
nifi cant drug interactions.25

Discharge from the hospital is
another crucial time for ensuring
medication accuracy and maintain-
ing patient safety. Less than half of 43
patients in a New York City hospital
remembered medication-related in-
formation (i.e., name, purpose, and
major adverse effects) at discharge.27

An accurate assessment of a patient’s
medications during hospitalization,
along with knowledge of medica-
tions taken at home, is necessary to
write correct discharge medication
orders and educate the patient about
medications that are to be continued
on an outpatient basis. Without a
standardized process for medication
reconciliation, the reliability of the
information recorded at admission
is variable and can be infl uenced by
the training and background of the
personnel involved, the time allotted
with the patient, and the patient’s
level of familiarity with his or her
drug therapies.

Although pharmacist-conducted
medication histories and discharge
counseling are considered desir-
able clinical pharmacy services, only
about 5% of U.S. hospitals reported
having pharmacists in these roles
in 2002.2 More recently, 44.8% of
hospitals surveyed reported having
a medication reconciliation system
in place; however, the report did not
reveal whether pharmacists had a
role in medication reconciliation.28

This increase in the implementa-
tion of medication reconciliation
systems likely refl ects a new focus
on this service by the Joint Commis-
sion on Accreditation of Healthcare
Organizations. The American Soci-
ety of Health-System Pharmacists
(ASHP), in its ASHP Health-System
Pharmacy 2015 Initiative, has stated
that pharmacists should be involved
in managing the acquisition of
medication admission histories and
provision of discharge counseling

for 75% of hospital inpatients with
complex and high-risk medication
regimens by 2015.29 A previous pilot
study conducted at our hospital16 and
other published literature30-36 dem-
onstrated that pharmacist-obtained
medication histories are efficient
and improve patient safety (Table 1).
However, many hospitals do not have
the funding and support necessary to
consistently provide this service.

Several articles explain the impor-
tance of medication reconciliation
documentation and include paper
forms for use in capturing the neces-
sary information at the time of hos-
pital admission,37-43 but few address
completing similar documentation at
discharge. Luther Midelfort Hospital
(Mayo Health System) has provided
one of the few published reports of
computer-generated discharge medi-
cation lists.39

Development of an electronic
process to streamline the fl ow of pa-
tients’ information is a relatively new
concept for many hospitals, but the
Department of Veterans Affairs has
been using such systems for many
years.44,45 North Mississippi Medical
Center, a regional integrated man-
aged health system, reported how
an electronic-based admission and
discharge medication reconciliation
process has helped pharmacists with
obtaining medication histories and
nurses with completing discharge
medication

processing.

46 At Thomas
Hospital in Fairhope, Alabama, an
automated process to retrieve patient
prescription medication histories
from insurance carriers or pharmacy
benefit management companies is
used to begin the medication recon-
ciliation process.47

P h a r m a c i s t s a n d nu rs e s co l –
laborate daily to provide patient-
centered care, particularly in the
m e d i c a tion-safety arena. 1 8 Both
disciplines are positioned to work to-
gether to perform medication recon-
ciliation documentation. Our hospi-
tal, Wesley Medical Center, located in
Wichita, Kansas, and licensed for 760

beds and 102 bassinets, developed an
electronic process for medication rec-
onciliation using our clinical patient
care system (CPCS) (Meditech, Inc.,
Boston, MA) to enable collaborative,
standardized, targeted, pharmacist-
and nurse-conducted admission and
discharge medication reconciliation
documentation. The goal of this
study was to evaluate the medication
reconciliation system’s feasibility and
effects on patient safety.

Method

We conducted a prospective study

in a 48-bed adult general medical
unit of our hospital. The study in-
vestigators included pharmacists and
nurses. Noninvestigators included
pharmacists, nurses, and physicians.
Pharmacists and nurses collaborated
to identify high-risk patients, obtain
the admission medication history,
and complete the electronic ad-
mission and discharge medication
reconciliation processes. A repli-
cable and generalizable model was
created by targeting the service to
high-risk patients, identifi ed through
a set of trigger questions complet-
ed by a nurse, and implementing
pharmacist-obtained patient ad-
mission medication histories and
discharge medication reconciliation
documentation. Technology was used
to enhance the multidisciplinary fl ow
of information.

This study was conducted in two
phases: a preimplemention phase
and a postimplementation phase.
In the preimplementation phase,
admission medication histories and
discharge medication counseling
followed standard care processes. A
nurse obtained each patient’s medi-
cation history and called the patient’s
physician for admission medication
orders. The nurse then handwrote
admission medication orders in the
physicians’ order section of the medi-
cal record. At discharge, the nurse
handwrote each patient’s medication
list and provided discharge coun-
seling. In the postimplementation

PRACTICE REPORTS Medication reconciliation

406 Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

phase, pharmacists and nurses col-
laborated to electronically complete
admission and discharge medication
reconciliation documentation. For
this study, medication reconciliation
was defi ned as an interdisciplinary
process involving nurses, pharma-
cists, and prescribers who collaborate
to decrease medication errors and
potential adverse events.48

Staff education. Nurse and phar-
macist education. Nurses and phar-
macists attended education sessions
before study initiation. Nursing edu-
cation was provided by investigators
at staff meetings and individually.
A fl ow chart was created to guide
nurses through the admission and
discharge medication reconciliation
documentation process. All pharma-

cists attended a three-hour, hands-on
computer education session. Before
pharmacists were scheduled to work
on the study unit, they completed an
electronic medication order-entry
competency evaluation covering
admission through discharge using a
test patient.

A medication history reference
sheet was available to pharmacists;

Pharmacist histories were time-effi cient; pharmacists
collected more information regarding prescription
and nonprescription medications, herbal
supplements, and allergies and made more clinical
interventions when allowed to conduct medication
history.

Face-to-face pharmacist interview was more accurate;
patient-completed form was neither eff ective nor
timesaving.

Pharmacist-conducted histories had fewer errors (32%
vs. 52%, p < 0.001) and fewer signifi cant errors (1.6% vs. 3.1%, p < 0.01).

Mean ± S.D. medication errors were reduced from
1.45 ± 0.39 to 0.76 ± 0.07; pharmacists and nurses
reported that new system was more accurate, safe,
and effi cien

Pharmacists recorded more prescription drugs (mean
5.6 ± 3.1 vs. 2.4 ± 1.3).

Pharmacists recorded at least one piece of additional
information in 95% of patients and more
prescription medication information for 54% of
patients; 11% of pharmacist-conducted histories
contained clinically signifi cant information missed
by physician.

Pharmacists found discrepancies in 98% of patients
(52/53) in the intervention group vs. physicians
fi nding discrepancies in 53% of patients (26/50);
pharmacists decreased drug cost at discharge by
22.5%, prevented 4 potential major (5%) and 48
moderate (43%) medication events, and decreased
drug costs by a predicted $500,000 per yr (25
admissions/day, 5 days/wk, 46 wk/yr); results
secured funding for a full-time clinical pharmacist to
participate in multidisciplinary rounds.

Table 1.
Studies Comparing Pharmacist-Conducted Medication Histories or Discharge Counseling with Those
Conducted by Other Disciplines

Comparisona

Ref. Disciplines Di
sc

ha
rg

Summary of ResultsAd
m

iss
io

Sig
ni

fi c
an

Sa
tis

fa
cti

Fe
as

ilit

Pharmacists and nurses

Patients and pharmacists

Pharmacists and
unspecifi ed “usual
process”

Pharmacy technicians and
nurses

Pharmacists and physicians

Pharmacists and physicians
Pharmacists and physicians

aSignifi cance = some type of clinical signifi cance assigned to the prevented or actual medication error, satisfaction = satisfaction with new process measured in some
fashion, feasibility = feasibility, cost-eff ectiveness, or eff ect on personnel time evaluated in some fashion.

×
×
×
×
×
×
×
×
×
×
×
×

PRACTICE REPORTS Medication reconciliation

407Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

the reference gave examples of pa-
tient medication history interview
techniques (e.g., open-ended ques-
tions).49 Pharmacists recorded the
patient medication history using a
standardized form, which included
fi elds for patient name, height, and
weight; community pharmacist or
pharmacy name and number; al-
lergies and reactions; prescription
medications, nonprescription prod-
ucts and herbal supplements; home
medication dosage, route, frequency,
indication, and date and time last
taken; and reminders to request
information from the patient about
nonprescription products, herbal
supplements, patches, inhalers, eye
drops, and vitamins and to record
interventions electronically.

Physician education. Posters were
placed on the medical unit to edu-
cate physicians about the medication
reconciliation process, including
information on how to view medica-
tions in the CPCS, what to complete
on the reports, and whom to contact
with questions. Individual education
was provided for physicians who
frequently admitted patients to the
unit. In addition, patients enrolled in
the study had orange sheets placed in
the front of the medical record with
written instructions explaining how
to view medications in the CPCS,
what to complete on the reports, and
whom to contact with questions.

Care coordinator education. Care
coordinators are either registered
nurses or licensed social workers who
direct case management activities.
Since care coordinators often assist
with compilation of discharge or
transfer medication lists, investiga-
tors provided inservice education
to explain the medication recon-
ciliation documentation process.
Investigators also contacted nursing
homes and skilled-nursing facilities
to explain the intent of the medica-
tion reconciliation discharge and
patient medication discharge reports
and to obtain feedback for improve-
ment. Suggestions were taken into

consideration for future long-term
implementation plans.

Pharmacist order entry. Specifi c
problems created by study procedures
and related to pharmacist order entry
were addressed, and solutions were
developed before implementing the
medication reconciliation process.
The computer system did not have
a mechanism to inform nurses that
the home medications were not to be
administered during hospitalization,
so a method was devised to prevent
confusion. Special order types—HM
(home medication) and DM (dis-
charge medication)—were developed
in the CPCS for home and discharge
medications. These special order
types prevented home medications
from being visible to nurses in the
electronic medication administra-
tion record but allowed pharmacists
to view the medications throughout
each patient’s hospitalization. All
medications entered by the phar-
macist are normally accessible by
the nurse from computer-controlled
medication-dispensing cabinets in
patient care areas. A false (or dum-
my) doctor mnemonic, HM, was
created and used for all home and
discharge medication orders. The
automated medication-dispensing
cabinets were unable to recognize
this false doctor mnemonic and
therefore could not visualize home
or discharge medications for nurses,
preventing access to medications that
were not to be administered during
hospitalization.

Nonformulary items were entered
using the same special order types.
All home and discharge medications
defaulted to one-minute stop times
to allow medications to drop off of
the pharmacist’s order-entry screen,
leaving only inpatient orders active.
Additional lines and special instruc-
tions were added for discharge medi-
cations with a tapering schedule (e.g.,
prednisone).

After home medications were en-
tered, the home medication profi le
was locked to prevent pharmacists

from accidentally modifying the
admission medication history. A spe-
cial function was created to lock the
medication profi le by editing patient
data. To lock the profi le, the phar-
macist completing the medication
history answered yes to the question
“Home profi le entered?” in the Edit
Patient Data screen.

The home medication profile
was accessible to all providers on
the Patient Care Inquiry screen.
Instructions for accessing the home
medication profi le for viewing in the
CPCS were placed in the front of the
patient medical record. Nurses and
pharmacists were provided hand-
outs explaining how to access this
information.

Report development. Four re-
ports were developed for medica-
tion reconciliation documentation:
(1) home medication profi le report,
(2) home medication reconciliation
report, (3) discharge medication
reconciliation report, and (4) pa-
tient discharge medication profi le.
All reports contained information
required by Health Information
Management (HIM) to be retained as
a part of the permanent medical re-
cord. A meeting with HIM also estab-
lished sections of the medical record
where reports would be placed.

Home medication reports. Each
report was developed with a specifi c
purpose in mind. The home medi-
cation profi le report and the home
medication reconciliation report
were generated at the same time and
presented the same information in
different formats. The home medica-
tion profi le report listed the home
medication history for reference; this
report was placed in the History &
Physicial/Education Record section
of the medical record. The home
medication reconciliation report
listed the medication history and in-
cluded a physician signature line and
date (Figure 1). This report was used
to reconcile the home medication
history with the inpatient admission
medication orders and was placed in

PRACTICE REPORTS Medication reconciliation

408 Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

Figure 1. Home medication reconciliation report.

the physicians’ order section of the
medical record.

Discharge reports. The discharge
medication reconciliation report
(Figure 2) was printed by an inves-
tigator and placed in the Physicians
Order section of the medical record
daily before physicians conducted
rounds. The discharge medication
reconciliation report could also be
printed on demand by nurses and
pharmacists. This report grouped
home medications and active inpa-
tient medications by the American
Hospital Formulary Service (AHFS)
drug classifi cation to prevent medi-
cation duplication at discharge.

Medication duplication often oc-
curs when medications are changed
to hospital formulary products. For
example, a patient leaves the hospital
with a prescription for famotidine,
the hospital’s formulary product,
and continues to take ranitidine, a
home medication prescribed before
hospital admission. Prescribers used
the discharge medication reconcilia-
tion report to indicate what medica-
tions patients should be taking after
discharge.

The patient discharge medication
profi le was created after the phar-
macist entered any new discharge
medications. Two copies of the pro-

fi le were printed: one to give to the
patient and one to put in the patient
medical record (Figure 3). The report
printed medication instructions in
lay language if drug dictionary ad-
ministration frequencies were used at
the time of order entry. Pharmacists
were instructed to enter lay language
instructions for all orders during ini-
tial order entry.

A search feature was programmed
into the patient discharge medica-
tion profi le to scan for new medica-
tions continued at discharge. The
following alert appeared on the
report below each new medication:
“Nurse, please print patient instruc-

PRACTICE REPORTS Medication reconciliation

409Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

tion sheet for this medication.”
Nurses printed patient instructions
for new medications from a com-
mercially available online drug
information service written in lay
language (Lexi-Comp Online, Hud-
son, OH). The patient discharge
medication profi le and new medica-
tion instructions were provided to
the patient at discharge.

Figure 2. Discharge medication reconciliation report.

Patient enrollment. Patient en-
rollment occurred during the fi rst
work shift (7:00 a.m. to 3:30 p.m.),
Monday through Friday, September
13, 2004, through February 28, 2005,
for the preimplementation phase
and May 6, 2005, through October
21, 2005, for the postimplementa-
tion phase. The study protocol and
patient informed consent were ap-

proved by the local scientifi c review
committee and institutional review
board (IRB). Initially, all patients
provided written informed consent
to participate in the study. However,
after study initiation, an exemption
for written informed consent was ob-
tained from the IRB, and subsequent
patients provided only oral consent
before study participation.

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410 Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

Potential study participants were
identifi ed through a set of trigger
questions that the nurse asked pa-
tients during the admission assess-
ment. Trigger questions included the
following:

1. Do you take seven or more medica-
tions (total number of prescrip-
tion, nonprescription, and herbal
products)?

2. Do you have asthma?
3. Do you have chronic obstructive pul-

monary disease (COPD)?
4. Do you have diabetes?
5. Do you have any cardiac condition

(e.g., myocardial infarction [MI],
congestive heart failure [CHF], ar-
rhythmia, hypertension)?

6. Were you admitted with an adverse
drug reaction?

7. Do you need to be vaccinated against
pneumococcal disease (i.e., never re-
ceived the Pneumovax immunization
or received it over fi ve years ago)?

8. Do you need to be vaccinated against
infl uenza (i.e., not yet vaccinated this
year)?

9. Do you have more than three medi-
cation allergies?

10. Do you have medications that need
to be identifi ed?

A positive response (yes) to one or
more trigger questions notifi ed a
pharmacist through an electroni-
cally generated report. Trigger ques-
tions were based on those developed
in a previous pilot study at our
hospital.16

Once identified, patients were
evaluated to determine whether they
met study inclusion criteria. To be
included in the study, patients had
to be general medical patients age
18 years or older, be admitted to
the study unit, and provide written
or oral informed consent. Patients
were excluded if a nursing medica-
tion history was obtained more than
2 hours after admission, they were
admitted for 23-hour observation,
they transferred to or from another
hospital unit, their admission was
due to intentional drug overdose, or
they could not provide consent. The
rationale for excluding patients when
the nursing medication history was
obtained over 2 hours after admis-
sion was to avoid confounding fac-

tors affecting medication reconcilia-
tion during a prolonged time period
compared with the postimplementa-
tion phase. Translators were obtained
for non-English-speaking patients,
so such patients were not excluded.
Patients who met study inclusion
criteria and consented to participate
were followed from admission to
discharge. All study data were kept
in a locked fi le cabinet in a pharmacy
satellite offi ce. Keys to the fi le cabinet
were kept in a computer-controlled
medication dispensing cabinet in the
patient care area.

Preimplementation phase. Ad-
mission and discharge. A standardized
data collection form was completed
for each patient by an investiga-
tor. The form included the follow-
ing information: inclusion criteria,
verifi cation that no exclusion criteria
were met, study number assigned,
patient name, hospital identifi cation
number, length-of-stay information,
and the patient’s telephone number.
Consent information was placed in
the patient medical record. Patients
received the usual care provided on
this unit from all health care provid-

Figure 3. Patient discharge medication profi le.

PRACTICE REPORTS Medication reconciliation

411Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

ers: Nurses obtained the medication
history and performed medication-
related interventions (e.g., calls to
physicians were documented), and
pharmacists performed medication-
related interventions, documented
the time required to complete the in-
terventions, and processed admission
medication orders as usual.

Pharmacist and nurse interventions.
Pharmacists completed interventions
electronically, the standard method
for all intervention documentation
in the pharmacy department during
both phases of the study. To cap-
ture nursing interventions, a home
medication clarifi cation intervention
was created for nurses to add to the
intervention documentation screen
in the CPCS. Pharmacist and nurse
interventions included the following
subcategories: (1) incomplete medica-
tions, (2) medication duplications, (3)
route changes, (4) dosage changes, (5)
adverse drug reactions, (6) drug inter-
actions, (7) vaccine recommendations,
(8) laboratory test recommendations,
(9) allergy documentation changed,
(10) missing medications, (11) non-
prescription medications identified,
(12) herbal products identifi ed, (13)
medication histories clarifi ed through
a patient’s retail pharmacy, and (14)
time to enter allergies into the com-
puter. Defi nitions used for all inter-
vention documentation are provided
in the appendix.

Postimplementation phase. Ad-
mission. Before study initiation, an
electronic process for medication
reconciliation documentation was
developed and programmed. After
the patient assessment was conduct-
ed by a nurse and informed consent
obtained, consent information was
placed in the patient medical record.
Patients meeting inclusion criteria in
the postimplementation phase had
medications electronically reconciled
as follows (Figure 4):

1. After enrollment, pharmacists ob-
tained the patient medication his-
tory in a private area for patient
confidentiality.

Figure 4. Admission medication reconciliation process.

Patient admission
assessment taken by

nurse.

Yes

Nurse takes home medication
history and documents

medications in the admission
history.

Nurse prints home medication
history and places in patient chart.

Nurse calls physician to obtain
patient admission orders and to
review home medication history.

Home medication history is
marked to refl ect admission

orders.

Inpatient profi le is entered into
pharmacy module by the

pharmacist.

Trigger report printed in pharmacy
by the Meditech system.

Pharmacist obtains patient
medication history and verifi es

using multiple resources.

Pharmacist takes home medication
profi le and documents medications

in the Meditech system.

Pharmacist “locks” the patient home
medication profi le in the Meditech

pharmacy module.

Pharmacist prints the home
medication reconciliation report and
places in the physician order section

of the patient chart.

Pharmacist and nurse coordinate
contacting the physician to complete

the admission reconciliation.

Physician called to obtain patient
admission orders and to reconcile

home medications.

Home medication reconciliation
report is marked to refl ect reconciled

medications to be continued on
admission. The report is scanned to

pharmacy for order processing.

Does
patient meet trigger questionpatient meet trigger questionpatient meet trigger questionpatient meet trigger questionpatient meet trigger question

criteria?

Home medication history report
is scanned to pharmacy for order

processing.

PRACTICE REPORTS Medication reconciliation

412 Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

2. Pharmacists created the electronic pa-
tient home medication profi le using
multiple resources to establish an ac-
curate medication history and locked
the computerized patient profile,
verifying the medications were home
medications (Figure 5).

3. Once the home medication profi le
was locked, the home medication rec-
onciliation report was generated for
prescribers to use to reconcile medi-
cations on admission. Nurses and
pharmacists worked with prescribers
to complete admission medication
reconciliation documentation.

4. Interventions captured during admis-
sion medication reconciliation were
electronically recorded and catego-
rized by nurses and pharmacists.

Discharge. Discharge medica-
tions were electronically reconciled
through the following process:

1. The discharge medication reconcili-
ation report, available in the front of
the medical record or printed on
demand, was used to reconcile medi-
cations. This computer-generated re-
port contained the home medications

and the active inpatient medications,
listed by AHFS drug classification
(Figure 2).

2. The prescriber marked through or
wrote “discontinue” for medications
not to be continued after discharge.
When the prescriber completed this
process, the report was electronically
scanned and sent to the pharmacist.

3. The pharmacist verified that the
medication reconciliation process was
completed. If it was not, the nurse and
pharmacist worked together to call
the physician to obtain any clarifi ca-
tion needed.

Figure 5. Pharmacist order-entry screen.

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413Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

4. The pharmacist then printed the
patient discharge medication profi le,
which listed all medications the pa-
tient should be taking after discharge
in lay language. The nurse used the
patient discharge medication profi le
for discharge instructions, thereby
eliminating the need for handwritten
medication instructions (Figure 3).

5. The nurse provided information
for new medications written in lay
language. After nurses provided med-
ication information and discharge in-
structions, pharmacists were available
for discharge counseling if patients
had further questions.

6. Interventions completed during dis-
charge were electronically recorded and
categorized by nurses and pharmacists.

Outcomes measures. This study
evaluated the (1) feasibility and ef-
fi ciency of nurse-initiated, targeted,
pharmacist-conducted medication
histories and admission and dis-
charge medication reconciliation, (2)
the effect of this clinical service on
patient safety, and (3) the satisfac-
tion of patients, prescribers, nurses,
and pharmacists with this clinical
service.

Feasibility and effi ciency. Timed
studies were completed to determine
personnel resources required to
implement this service. On admis-
sion, the time for the nurse to obtain
initial medication assessment and
the time for the pharmacist to enter
and clarify initial home medications,
including patient medication assess-
ment, were measured. At discharge,
the time required for nurses to com-
plete medication discharge instruc-
tions and paperwork, for pharma-
cists to print reconciliation reports
and provide discharge counseling,
and for prescribers to complete
medication-related paperwork and
write discharge prescriptions was
measured.

Nursing and pharmacy admis-
sion and discharge medication rec-
onciliation accuracy was measured
by the mean number of prescrip-

tion medications, nonprescription
medications, herbal products, allergy
descriptions, and medication dupli-
cations identified. Nursing, phar-
macy, and prescriber completeness
of medication-related admission and
discharge documentation was mea-
sured as the percentage of patients
with incomplete allergy descriptions
(explanation of allergic reaction),
medications (dosage, schedule, time
of last dose taken, indication), vac-
cination documentation, and allergy
documentation (allergies identifi ed
and documented in the computer
system).

Patient safety. The number and
type of potential errors prevented at
admission and discharge were identi-
fi ed by the mean number and type
(intervention subcategory) of recon-
ciliation interventions or discrepan-
cies documented in the computer-
ized database. Severity of potential
errors prevented were categorized
using the hospital’s policy for cat-
egorizing medication errors and the
30-day readmission rate.50

Patient and health care profes-
sional satisfaction. Patient, prescriber,
nurse, and pharmacist surveys were
conducted using a fi ve-point Likert
scale to assess satisfaction with the
medication reconciliation process.

Patient satisfaction survey.Patient satisfaction survey. At
the time of admission or shortly
thereafter, patients in both groups
were offered the opportunity to
participate in a telephone satisfac-
tion survey to occur after discharge
from the hospital. Patients willing to
participate provided contact infor-
mation to one of the investigators.
Researchers attempted to contact all
patients willing to participate as soon
as possible after discharge. Attempts
to contact these patients continued
for up to 14 days after discharge. If
requested, a family member was al-
lowed to answer the survey questions
if the patient was unable to come to
the telephone (only an option if the
family member was present when the
patient was discharged).

The same scripted survey was
used for all patients. The survey uti-
lized a fi ve-point Likert scale, where
1 = strongly disagree, 2 = disagree,
3 = undecided, 4 = agree, and 5 =
strongly agree. Patients were asked to
respond to the following fi ve state-
ments using this scale:

1. When I was discharged from the
hospital, I was given clear instruc-
tions about which medications I
was supposed to continue taking at
home.

2. I was given clear directions about how
much and how often I am supposed
to take my medications.

3. I was given clear directions how and
when to take my medicine (e.g.,
take medications with food or on an
empty stomach, in the morning only
or at bedtime only).

4. I was given clear information about
possible side effects of my medicine.

5. Overall, I feel like I understand my
medicines.

After completion of this survey por-
tion, patients were asked the follow-
ing questions:

1. Did you receive any new prescriptions
when you were dismissed from the
hospital? If they answered yes, they
were asked, Did you have all the new
prescriptions fi lled? If they did not,
they were asked, Can you tell me why
you did not have them fi lled?

2. Do you have any additional questions
about your medications?

3. Do you remember talking to a phar-
macist about your medications while
you were in the hospital?

Telephone surveyor training.Telephone surveyor training. All
researchers conducting telephone
surveys successfully completed a
questionnaire measuring compre-
hension of a review of survey design
methodology, telephone survey eti-
quette, and avoidance of bias in tele-
phone surveys modeled from Health
Research and Design Methodology.51

Although all researchers completed

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414 Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

the telephone survey competency,
primarily three researchers conduct-
ed the telephone surveys. For non-
English-speaking patients, a trans-
lator was utilized. This translator
received abbreviated oral training be-
fore contacting each patient. Proper
etiquette training included impor-
tance of confi dentiality, being cour-
teous and professional, introduction
of self, purpose of the telephone
call, and responding to those who
declined participation. Avoidance
of bias training included avoiding
deviation from the scripted survey,
appropriately clarify ing unclear
questions, utilizing a neutral voice,
not rushing the respondent, and
avoiding expression of satisfaction or
dissatisfaction with the respondent’s
answers. If a patient did have addi-
tional questions regarding medica-
tions, the surveyors were instructed
to write down the questions and tell
the patient that a letter would be sent
to his or her physician for follow-up.

Health care professional survey.Health care professional survey. At
the end of both the preimplementa-
tion and postimplementation phases,
surveys were completed by nurses,
pharmacists, physicians, nurse prac-
titioners, and physician assistants.
The survey utilized a fi ve-point Lik-
ert scale, where 1 = strongly disagree,
2 = disagree, 3 = undecided, 4 =
agree, and 5 = strongly agree. They
were asked to respond to the follow-
ing fi ve statements:

1. Patients are provided clear instruc-
tions about which medications they
are to continue at home (previous
home medications and any new dis-
charge medications).

2. At the time of hospital discharge,
patients have a clear understanding
of how much, how often, and when to
take their medications at home.

3. Most patients receive written infor-
mation about new medications prior
to discharge.

4. The patient medication discharge
process is effi cient for me as a health
care provider.

5. I use the computer system on a
regular basis to view patient home
medications.

The last two questions allowed the
health care professionals to write in
comments and suggestions about
how they would improve the patient
medication discharge process.

Statistical analysis. Power analy-
sis indicated that 48 patients were
needed in each group to achieve
statistical signifi cance (two-sided

< 0.05) using α = 0.05 (two-sided) and β = 0.20. Primary outcome vari- ables were evaluated to determine whether or not they approximated a Gaussian distribution. Variability was assessed using the mean, median, and standard deviation. Finally, 95% confi dence intervals (CIs) were con- structed to assess whether the range of values included the true popula- tion values. For normally distributed data, parametric statistical tests were used. For study results not follow- ing Gaussian distribution, we used nonparametric statistical tests. Data were analyzed with GraphPad InStat (GraphPad Software, San Diego, CA). Patient survey data utilizing the Likert scale were compared using the Mann–Whitney U Test. Categorical U Test. Categorical U data were analyzed using Fisher’s exact test. Continuous variables were compared using the unpaired t test. t test. t Statistical signifi cance was set a priori at p < 0.05.

Results
Patient characteristics. A total

of 283 patients were included in the
study: 147 patients were enrolled
during the preimplementation phase
and 136 patients in the postimple-
mentation phase. The study popula-
tion consisted of patients with mul-
tiple medical problems, including
diabetes mellitus, asthma, COPD,
cardiac conditions, and pneumonia,
with an average length of stay of 5.7
days in the preimplementation phase
and 5.5 days in the postimplementa-
tion phase (Table 2).

Patient responses to most trigger
questions did not signifi cantly differ
between groups (preimplementation
and postimplementation); however,
significantly more patients in the
postimplementation group were
taking seven or more medications (p
< 0.0001; 95% CI, 0.5284–0.7604) and had a history of coronary artery disease (CAD) (p < 0.0001; 95% CI, 0.3274–0.5444) (Table 2).

Patients in the postimplementa-
tion group took signifi cantly more
prescription and nonprescription
medications, and their total number
of medications signifi cantly exceeded
the number taken by the preimple-
mentation group (Table 3).

F e a s i b i l i t y a n d e f f i c i e n c y.
Investigator-timed studies revealed
that, in the postimplementation
phase, pharmacists completed the
admission medication history in
12.9 ± 9.34 minutes, clarifi ed medi-
cations in 1.18 ± 5.84 minutes, and
performed interventions in 1.4 ±
2.25 minutes. Pharmacists’ mean ±
S.D. self-documented time to obtain
patients’ admission history in the
postimplementation phase was 16.3
± 17.5 minutes. Prescribers com-
pleted the admission and discharge
medication reconciliation process for
78 patients (57.4%). Prescribers did
not complete admission medication
reconciliation for 10 patients (7.3%),
whereas discharge medication rec-
onciliation was not completed for 34
patients (25%). A total of 14 patients
(10.3%) were discharged from an-
other area of the hospital, left against
medical advice, or died.

Pharmacist interventions. Types
of interventions pharmacists com-
pleted during the study included
eliminating drug therapy duplication;
correcting incomplete, missing, or
incorrect dosage or frequency infor-
mation; documenting allergies; and
providing laboratory test and vac-
cine recommendations. Pharmacists
completed signifi cantly more dosage
changes in the postimplementation
phase than in the preimplementation

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415Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

phase (Table 4). As expected, phar-
macists in the preimplementation
phase identifi ed no allergies, since
they were not directly involved in
obtaining the patient history; how-
ever, 24 allergies in 17 patients were
identified in the postimplementa-
tion phase (p < 0.0001). A total of 50 retail pharmacies were called during the postimplementation phase to

provide patient medication infor-
mation. Pharmacists completed 24
interventions in the preimplementa-
tion phase and 48 total interventions
in the postimplementation phase (p
= 0.0003).

Nurse interventions. In the pre-
implementation phase, nurses iden-
tifi ed more incomplete medication
orders, dosage changes, and allergies

than they did in the postimple-
mentation phase (Table 4). Nurses
completed 59 total interventions in
the preimplementation phase and 27
total interventions in the postimple-
mentation phase (p = 0.0003).

Time variables. Computerized
allergy information availability was
defi ned as the time from patient ar-
rival on the unit until allergies were
documented in the computer. The
mean ± S.D. time required for nurses
to enter allergies in the computer
was signifi cantly longer in the post-
implementation phase (141.1 ± 238.8
minutes versus 69.1 ± 98 minutes)
(p = 0.0315). The time required for
pharmacists to enter allergies de-
creased in the postimplementation
phase (64.1 ± 38.7 minutes versus
112.9 ± 70 minutes) (p < 0.0001). These changes occurred because the nurse was primarily responsible for the medication history in the preim- plementation phase, while the phar- macist was primarily responsible for the medication history in the post- implementation phase. Time from admission to trigger notifi cation did not signifi cantly differ between the groups. The mean ± S.D. time re- quired by pharmacists to initiate the admission medication history after receiving trigger notification was 18.8 ± 20.2 minutes (range, 1–140 minutes).

Mean ± S.D. no. prescription medications 4.9 ± 3.5 6.2 ± 4.3 0.0059
(0.3779–2.2222

)

Mean ± S.D. no. nonprescription medications 1 ± 1.6 2 ± 1.9 <0.0001 (0.5872–1.413) Mean ± S.D. no. herbal supplements 0.1 ± 0.34 0.1 ± 0.6 N

Mean ± S.D. total no. medications 6 ± 4 8.3 ± 5.2 <0.0001 (1.208–3.392) No. (%) patients receiving vaccinations 142 (97) 136 (100) NS

Table 3.
Results of Admission Medication Reconciliation in Preimplementation and Postimplementation
Groups

Postimplementation
(n = 136)Variable

Preimplementation
(n = 147) p (95% CI)a

aCI = confi dence interval, NS = not signifi cant.

Mean ± S.D. age, yr 64.4 ± 16 65.7 ± 17.6
Male, % 50 51
Mean ± S.D. height, cm 169.5 ± 18.3 169.2 ± 10.3
Mean ± S.D. weight, kg 81.8 ± 26.4 81.8 ± 24.3
Mean ± S.D. length of stay, days 5.9 ± 5.6 5.9 ± 6
No. (%) patients with admission

diagnosis
Angioplasty 16 (11) 16 (12)
Ankle swelling 55 (37) 52 (38)
Arrhythmia 36 (24) 35 (26)
Asthma 18 (12) 18 (13)
Coronary artery disease 47 (32) 103 (76)b

Cardiac catheterization 44 (30) 45 (33)
Congestive heart failure 26 (18) 32 (24)
COPDc 10 (7) 12 (9)
Diabetes mellitus 42 (29) 42 (31)
Hypertension 81 (55) 75 (55)
Myocardial infarction 27 (18) 27 (20)

Table 2.
Characteristics of Patients in the Preimplementation and
Postimplementation Groupsa

Characteristic
Preimplementation

(n = 147)
Postimplementation

(n = 136)

aUnless otherwise specifi ed, comparisons were not signifi cant.
bp < 0.0001. cCOPD = chronic obstructive pulmonary disease.

PRACTICE REPORTS Medication reconciliation

416 Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

Timed studies of selected study
activities were completed for both
study groups. Pharmacists completed
the admission medication history in
12.9 ± 9.34 minutes, clarifi ed medi-
cations in 1.18 ± 5.84 minutes, and
performed interventions in 1.4 ± 2.25
minutes.

Readmissions. In the preimple-
mentation phase, 17 patients were
readmitted 18 times within 30 days
after discharge, compared with 8
patients readmitted 8 times in the

postimplementation phase. In the
preimplementation phase, 9 patients
(10 visits) were seen in the emergency
department (ED), and 12 patients in
the postimplementation phase had a
total of 19 ED visits. Neither compari-
son yielded signifi cant differences.

Patient safety. Although attempts
were made to determine potential
medication errors, the effect of the
medication reconciliation process
on medication errors could not be
determined due to the lack of in-

tervention documentation in both
study phases. Category B and C
medication errors were discovered
during documentation of admission
medication history and reconcilia-
tion. Three medication errors were
reported during the preimplementa-
tion phase: two category B errors and
one category C error. Four medica-
tion errors were reported during the
postimplementation phase: three
category B errors and one category
C error. In the postimplementation

Table 4.
Number of Patient Interventions by Discipline

Postimplementation
(n = 136)Intervention Type and Discipline

Preimplementation
(n = 147) p (95% CI; RR)a

Incomplete medications
Pharmacist 8 in 4 pts 4 in 4 pts NSa

Nurse 24 in 8 pts 6 in 4 pts 0.0016
(1.56 to 8.779; 3.701)
Duplicate medications
Pharmacist 5 in 2 pts 3 in 3 pts NS
Nurse 5 in 2 pts 0 NS
Route changes
Pharmacist 0 0 NS
Nurse 0 0 NS
Dosage changes
Pharmacist 5 in 3 pts 15 in 12 pts 0.0184
(0.1151 to –0.8259; 0.3084)
Nurse 11 in 7 pts 0 0.0009
Adverse drug reactions
Pharmacist 1 in 1 pt 1 in 1 pt NS
Nurse 1 in 1 pt 0 NS
Drug interactions
Pharmacist 0 0 NS
Nurse 0 0 NS
Vaccination recommendations
Pharmacist 0 0 NS
Nurse 1 in 1 pt 0 NS
Laboratory recommendations
Pharmacist 0 0 NS
Nurse 0 0 NS
Allergies identifi ed
Pharmacist 0 24 in 17 pts <0.0001 Nurse 10 in 5 pts 21 in 14 pts <0.0227 (0.3518 to 1.001; 0.5934) Allergies changed Pharmacist 5 in 2 pts 1 in 1 pt NS Nurse 1 in 1 pt 0 NS Incomplete allergies Pharmacist 0 1 NS Nurse 0 0 NS

aCI = confi dence interval, RR = relative risk, NS = not signifi cant.

PRACTICE REPORTS Medication reconciliation

417Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

phase, completed home medication
reconciliation reports not scanned to
the pharmacy for order-entry proc-
essing contributed to the greatest
number of medication errors. The
completed home medication recon-
ciliation reports were processed but
not in a timely manner because of
scanning delays.

Patient satisfaction survey re-
sults. Results from the patient satis-
faction survey are listed in Table 5. In
the preimplementation phase, 63%
of patients were contacted within
14 days after hospital discharge,
compared with 50% in the post-
implementation phase (p = 0.002),
and agreed to participate in the tele-
phone survey. The average length of
time between discharge and patient
contact was shorter in the postimple-
mentation phase (p = 0.031). Patients
seen during the postimplementation
phase reported a signifi cantly higher
level of agreement on all fi ve state-
ments regarding adequate discharge
medication instructions (Table 5). A
total of 35 patients (8%) in the pre-
implementation group remembered
speaking with a pharmacist about
medications while in the hospital,
compared with 68 patients (63%) in
the postimplementation group (p < 0.001). Interestingly, no additional questions regarding medications were asked during the telephone sur- vey in either group.

Health care provider satisfac-
tion survey results. Results from
the health care provider survey are
provided in Table 6. Physician, nurse,
and pharmacist responses for all
questions did not signifi cantly differ
between the preimplementation and
postimplementation phases. Nurse
practitioners and physician assistants
reported decreased satisfaction with
patient understanding of medica-
tions at discharge and patient dis-
charge instructions and did not feel
that the discharge process was more
effi cient in the postimplementation
phase (n = 5) than in the preimple-
mentation phase (n = 15). Ta

b
le

5
.

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e.

PRACTICE REPORTS Medication reconciliation

418 Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

Ta
b

le
6

.
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lt
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(9

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%

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1
5

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±

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±

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9
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4
±

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±

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3
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)
1
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±
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±
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4

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S
1
1

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±
1
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7

1
0

2
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±
1

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6

N
S
1
9

3
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7
±

1
.0

1
3

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5

±
1

.0
7

N
S
1
5

3
.6
7
±
1
.2
9

2
.8

±
0

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4

N
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1
5

2
.2
±
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1
2

2
.4
±
1
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6

N
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1
1

3
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7
±
1

1
0

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±
1
.0
3

N
S

1
9

2
.8
4
±
1

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7

1
3

3
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6
±
1
.0
5

N
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1
5

3
.9
3
±
0

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9

2
.6
±

0
.5

0
.0
0
0
3

(–
1

.9
6

1
t

o
–

0
.6

9
9

3
)

1
5

.8
±

1
.3

1
2

.9
±

1
.2
4

N
S
1
1

2
.6
4
±
0

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2

1
0

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.3
±
1

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6

N
S
1
9

2
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6
±
1
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5

1
3

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9

±
1

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5

N
S
1
5

2
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4
±

1
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±
1
.1

N
S
a B
as
ed
o
n
a
fi
ve
-p
o
in
t
Li
ke
rt
s
ca
le
, w
h
er
e
1
=
s
tr
o
n
g
ly
d
is

ag
re

e
an
d
5
=
s
tr
o
n
g
ly
a
g
re
e.

b
C

I =
c

o
n

fi
d

en
ce

in
te

rv
al

, N
S

=
n

o
t

si
g

n
ifi

ca
n

n
M

e
an

±
S

.D
.

R
at

in
g
a
n
M
e
an
±
S
.D
.
R
at
in
g
a

PRACTICE REPORTS Medication reconciliation

419Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

Discussion
The electronic medication rec-

onciliation documentation process
developed and implemented at our
institution could be adapted and
implemented in other facilities.
Requirements for successful im-
plementation include adequately
staffed pharmacist personnel to
expand the reconciliation docu-
mentation process hospitalwide, the
ability of nurses and pharmacists
to collaborate with prescribers, and
the availability of technical support.
Until computerized prescriber order
entry is implemented at our institu-
tion, the medication reconciliation
process will require prescribers to
handwrite changes on the printed
reports.

Hospital admissions occur dur-
ing all hours throughout the week.
During our study, the majority of
admissions occurred during the sec-
ond shift, and we had not planned for
study coverage to complete the rec-
onciliation process during this time.
To continue pharmacist-obtained
medication histories and electronic
discharge reconciliation, it would
take at least two additional pharma-
cists solely devoted to medication
reconciliation to continue the pro-
cess in limited areas of the hospital,
such as the ED, for an annual total
cost of $180,000 plus benefi ts.

Developing and implementing
electronic medication reconciliation
documentation was challenging.
The greatest diffi culty encountered
regarding data collection in the
study was the lack of documentation
of pharmacist and nurse interven-
tions. A special screen to document
interventions electronically was cre-
ated for our CPCS for nurses, but the
nurses had to add the documenta-
tion screen for each patient to record
interventions. Nurses continued to
document interventions in a variety
of locations for patients in the post-
implementation phase, making it
diffi cult for investigators to fi nd and
retrieve information.

Pharmacists were instructed to
use the usual electronic process to
document interventions; however,
multiple steps in the electronic medi-
cation process often resulted in a lack
of intervention documentation. Re-
minders were sent, and one-on-one
education was frequently provided.
The complexity of the process likely
detracted from the staff ’s willing-
ness and ability to capture interven-
tions. The fact that at least 50 retail
pharmacies were called to obtain
patient medication lists, yet only 48
individual interventions were docu-
mented, indicates that the number
of home medication clarifications
was not accurately captured. In addi-
tion, pharmacists interpreted calls to
pharmacies as new orders rather than
order clarifi cations, since a prescriber
was not involved. Therefore, phar-
macists did not include these calls in
their interventions.

The time required for pharmacists
to complete the medication history
(12.9 ± 9.34 minutes) was similar to
the time spent in a previous pilot
study at our hospital (13.4 ± 6.7 min-
utes).16 In the present study, the time
pharmacists spent clarifying medi-
cations (1.18 ± 5.84 minutes) and
performing interventions (1.4 ± 2.25
minutes) was less than the 6 ± 6.5
minutes it took pharmacists to rec-
oncile subsequent home medication
orders in the pilot study.16 The time
difference may have been attribut-
able to timed evaluations in the cur-
rent study versus self-documented
time in the pilot study.

One investigator prepared the
pharmacist schedule (26 full-time
equivalents) for the department;
pharmacists were scheduled to work
in one-week intervals throughout
the study to provide continuity.
Pharmacists not routinely working
on the study unit found it diffi cult to
complete the reconciliation process
without referring to fl ow diagrams or
calling investigators.

Nurse and pharmacist commu-
nication with physicians remained

challenging during the study. Phar-
macists and nurses worked together
to contact physicians to complete
admission and discharge recon-
ciliation. Although most physicians
returned pages, not all calls were
returned immediately. When calls
were returned, physicians preferred
to address admission medication
reconciliation during rounds, so the
reconciliation process was completed
during the second shift of the day or
the next day.

Discharge medication recon-
ciliation. Discharge medication
reconciliation was also diffi cult to
complete. Both nurses and pharma-
cists expressed frustration because
many prescribers did not complete
the discharge medication reconcili-
ation report, even when prompted.
Considerable time and effort were
spent during admission to ensure
the accuracy and completeness of the
medication list. In addition, time was
taken to develop, print, and place the
discharge medication reconciliation
form in the patient chart. A total of
34 patients (25%) in the postimple-
mentation group did not have their
discharge medication reconcilia-
tion report completed by physicians
before discharge, even though the
report was fl agged in the chart.

Some physicians indicated that
they appreciated the reports and the
completeness of the medications,
especially the discharge medication
reconciliation report. By listing med-
ications using AHFS classifi cation on
the discharge report, physicians were
able to easily visualize medication
duplications and prevent medication
errors at discharge. When physicians
were asked why they did not com-
plete the medication reconciliation
form, several said they viewed the
process as repetitive, since discharge
prescriptions still had to be writ-
ten. Initially, the investigators had
intended to create and incorporate
electronic physician-generated pre-
scriptions. However, the hospital had
already started to explore this op-

PRACTICE REPORTS Medication reconciliation

420 Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

tion, so it was decided before study
initiation not to include electronic
prescription capability during the
postimplementation phase.

Technical support. Technical sup-
port is required for the electronic
medication reconciliation process to
work smoothly. A dedicated pharma-
cy department computer program-
mer spent many hours program-
ming, testing, and resolving system
problems to make implementation
successful. Grant funding, together
with hospital-matched funds, sup-
ported the reconciliation develop-
ment and programming. Each time
the computer system was upgraded,
computer problems would prevent
reports from printing or cause them
to print incorrectly. Sometimes
after upgrades, pharmacists enter-
ing home or discharge medications
would be “kicked out” of the com-
puter system entirely, losing all of
their work. This wasted time, taking
from a few minutes to one hour to
reenter the lost data, and was frus-
trating. Each problem was addressed
rapidly during the study, but, for a
hospitalwide system, dependability
to complete the electronic process
and funding to support the program
cost are absolutely essential.

Patient participation and satis-
faction. It is unknown what infl u-
ence, if any, the difference in average
time between discharge and contact-
ing the patient may have had on the
survey outcome since the average dif-
ference was only approximately one
day. Common reasons for not being
able to contact patients during both
study phases included patient death
during hospitalization or after dis-
charge, patients being transferred to
other facilities (e.g., skilled-nursing
facilities) before returning to their
residence, incorrect patient phone
numbers obtained at admission, and
patients being too ill to communicate
or simply not wishing to participate
in the survey.

Overall, patients were very will-
ing to participate in the study. They

voiced a realization of the impor-
tance of health care providers and
patients working together to ensure
a complete medication review. Many
times, patients stated that they
wanted to participate because they
had experienced medication-related
diffi culties in the past or were being
admitted with medication-related
problems. Other patients had a fam-
ily member admitted or discharged
with medication-related diffi culties
in the past.

Study limitations. Although phar-
macists identifi ed more medications
in the postimplementation phase, the
results may have been skewed by two
important triggers: the number of
home medications on admission and
the diagnosis of CAD. Possible rea-
sons for this include the following:
(1) patients with CAD tend to take a
greater number of medications, (2)
nurses preferred for pharmacists to
complete medication histories for
patients on multiple medications, so
the trigger question asking about the
number of medications taken was
answered more frequently, and (3)
pharmacists elected not to complete
uncomplicated medication histories
if already completed by the nurse or
physician.

Our study required noninvestiga-
tors, such as physicians, nurses, and
pharmacists, to complete different
steps of the medication reconcilia-
tion process. As a result, documenta-
tion was not always complete. More
data may have been captured if our
study allowed total investigator in-
volvement in all steps of the process.

The admission reconciliation
process was much easier to complete
than the discharge reconciliation
process. There was a lack of physician
participation in the medication rec-
onciliation discharge process. Also,
patients anxious to leave the hospital
sometimes chose not to wait for a
fi nalized list of medications. Com-
pleting reconciliation at discharge is
a very important, but challenging,
goal. Future studies should investi-

gate creative solutions for discharge
reconciliation.

Conclusion
Patients who had their medica-

tions electronically reconciled re-
ported a greater understanding of
the medications they were to take
after discharge from the hospital,
including medication administration
instructions and potential adverse
effects.

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422 Am J Health-Syst Pharm—Vol 64 Feb 15, 2007

Appendix—Defi nitions of data points for disease, intervention, and time documentation

Adverse drug reactions
Asthma
Congestive heart failure
Dosage changes

Drug interaction

Duplicate medications
Hypertension
Incomplete medications
Laboratory recommendation

Medication error

Number of allergies identifi ed
Number of incomplete descriptions of allergies
Number of medication histories clarifi ed with

pharmacist
Number of medications
Number of missing medications

Nurse’s time to enter allergies into computer

Pharmacist’s time to enter allergies into
computer

Route changes
Time from patient admission until trigger

notifi cation
Time from trigger notifi cation until medication

history initiated
Vaccine recommendation

Mild, moderate, or severe using institution’s current policy regarding adverse drug reactions
Yes or no (obtained from nurse’s screening history)
Yes or no (obtained from nurse’s screening history)
Drug dosage increases or decreases based on laboratory test results (e.g., renal function, hepatic

function) or maximum and minimum recommended doses per the drug manufacturer
An identifi ed problematic interaction that could possibly cause an adverse drug reaction if continued

(not morphine causes itching or a purposeful drug interaction)
Duplications of therapeutic drug class
Yes or no (obtained from nurse’s screening history)
Missing information (drug name, strength, dosage schedule, time of last dose taken, indication)
Drug therapy recommended based on laboratory values, laboratory values recommended as a result

of drug therapy, laboratory values recommended based on previous laboratory results
Categories A through C classifi ed by National Coalition Council Medication Error Reporting

Program taxonomy; category A = circumstances or events that have the capacity to cause error,
category B = an error occurred but did not reach the patient, category C = an error occurred and
reached the patient but did not cause harm

Any additional allergies added to the patient profi le on admission; true allergies (not nausea)
Any allergy listed without an explanation of what the allergic reaction was to the drug implicated
Number of medications requiring a phone call to the patient’s retail pharmacist to verify drug,

strength, dosage, or reasons for use
Include vitamins as nonprescription medications
Additional medications the patient should be taking or was taking at home before admission identi-

fi ed by the nurse or pharmacist
Time difference between when the nurse documented the information in the computer system and

when the patient was admitted to the unit
Time difference between when the pharmacist documented the information in the computer system

and when the patient was admitted to the unit
Intravenous to oral or oral to intravenous (or other routes)
Time documented from the patient arriving on the unit to the time reported on the computer-

generated trigger notifi cation report
Time from computer-generated trigger notifi cation to the time the clinical staff pharmacist begins

the patient medication history (postimplementation phase only)
Any vaccine recommendation provided during the hospital stay

Data Point Defi nition

Article

Improving handoff communication from hospital

to home: the development, implementation and

evaluation of a personalized patient discharge letter

BIANCA M. BUURMAN1, KIM J. VERHAEGH1, MARIAN SMEULERS2,

HESTER VERMEULEN2, SUZANNE E. GEERLINGS3,

SUSANNE SMORENBURG4, and SOPHIA E. de ROOIJ1

1Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, Amsterdam, The
Netherlands, 2Department of Quality Assurance and Process Innovation, Academic Medical Center, Amsterdam,
The Netherlands, 3Department of Internal Medicine, Section of Infectious Disease, Academic Medical Center,
Amsterdam, The Netherlands, and 4Department of Quality, Cordaan, Amsterdam, The Netherlands

Address reprint requests to: Bianca Buurman, Department of Internal Medicine, Section of Geriatric Medicine, Academic
Medical Center, F4-135, PO Box 22600, 1100 DD Amsterdam, The Netherlands. Tel: +31-20-5665991; Fax: +31-20-5669325;
E-mail: b.m.vanes@amc.uva.nl

Accepted 21 March 2016

Abstract

Objective: To develop, implement and evaluate a personalized patient discharge letter (PPDL) to

improve the quality of handoff communication from hospital to home.

Design: From the end of 2006–09 we conducted a quality improvement project; consisting of a

before–after evaluation design, and a process evaluation.

Setting: Four general internal medicine wards, in a 1024-bed teaching hospital in Amsterdam, the

Netherlands.

Participants: All consecutive patients of 18 years and older, admitted for at least 48 h.

Interventions: A PPDL, a plain language handoff communication tool provided to the patient at

hospital

discharge.

Main Outcome Measures: Verbal and written information provision at discharge, feasibility of

integrating the PPDL into daily practice, pass rates of PPDLs provided at discharge.

Results: A total of 141 patients participated in the before–after evaluation study. The results from the

first phase of quality improvement showed that providing patient with a PPDL increased the number

of patients receiving verbal and written information at discharge. Patient satisfaction with the PPDL

was 7.3. The level of implementation was low (30%). In the second phase, the level of implementation

improved because of incorporating the PPDL into the electronic patient record (EPR) and professional

education. An average of 57% of the discharged patients received the PPDL upon discharge. The

number of discharge conversations also increased.

Conclusion: Patients and professionals rated the PPDL positively. Key success factors for implemen-

tation were: education of interns, residents and staff, standardization of the content of the PPDL,

integrating the PPDL into the electronic medical record and hospital-wide policy.

Key words: patient discharge, handover, patient-centered care, patient satisfaction, patient-centered communication

International Journal of Quality in Health Care, 2016, 28(3),

384

–390
doi: 10.1093/intqhc/mzw046

Advance Access Publication Date: 25 May 2016
Research Article

384

http://www.oxfordjournals.org

Introduction

Annually around 35 and 1.8 million patients are discharged in the USA
and the Netherlands, respectively [1, 2]. The transition from hospital to
home is a complex and vulnerable period for patients [3, 4]. Ineffective
discharge planning and lack of coordination of care can lead to decreased
patient satisfaction, adverse events (AEs) and a higher number of hospital
readmissions due to complications [5, 6]. Studies have shown that ∼20%
of medical patients experience an AE within 5 weeks of hospital dis-
charge [7, 8]. The most common AEs are adverse drug events (66%)
and process- and procedure-related injuries, such as an incorrect medica-
tion prescription (17%) [7, 9, 10]. Many AEs result from an inadequate
communication between the hospital personnel and the patient or his
general practitioner (GP) [8, 11]. Incomplete handover from the hospital
to the GP is common, particularly for medication management [12].

In addition, treatment or care provided during hospital admission
might have (permanent) consequences for a patient’s lifestyle in terms
of a new medication regimen, consequences or delayed complications
of hospitalization and restrictions in nutrition or activities of daily liv-
ing [13]. Approximately 70% of patients face permanent medication
changes after hospitalization [14].

Moreover, over the last few decades the length of hospital stay has
decreased [15]. Yet more patients with complex care needs and multi-
morbidity are admitted to the hospital. The consequence of these
changes is that the delivery of in-hospital care has to be provided in
a shorter period of time, and might suggest that patients with complex
care needs are send home before they are fully recovered.

Therefore, it is important to prepare these high-risk patients for hos-
pital discharge and provide them with well-defined patient-centered in-
structions, which enables them to maintain independent living, perform
self-management activities and reduce complications after hospital dis-
charge [16, 17]. Research has been moderately effective at improving
discharge services such as early discharge planning, medication recon-
ciliation, telephone calls after discharge and home visits to prevent
avoidable AEs after discharge [18, 19]. The most effective interventions
seem to be those that combine pre-discharge and post-discharge inter-
ventions with educational components [18]. Initiatives directed toward
patients to improve patient empowerment and to improve the informa-
tion provided to them at discharge are relatively scarce.

The objective of this quality improvement project was to evaluate
the development and implementation of a personalized patient dis-
charge letter (PPDL) on information provision at hospital discharge
and to study the feasibility, barriers and facilitators of integrating
the PPDL into daily practice.

Methods

Design, setting and ethical considerations

From 2006 to 2009, we conducted a quality improvement trajectory at
the Academic Medical Center, a 1024-bed university teaching hospital

in Amsterdam, the Netherlands with the aim to improve handoff com-
munication directed toward patients. We used two evaluation meth-
ods; a before–after study design interviewing patients about the
discharge information they received and how they valued the PPDL
(post-implementation only) and a process evaluation to study the
feasibility, barriers and facilitators of integrating the PPDL into
daily practice. Figure 1 shows the timeline of the quality improvement
trajectory. The measurements and data collection are described below.

The patients that participated were interviewed on how they per-
ceived the information at hospital discharge and not on personal in-
formation. The study was checked by the Institutional Review Board
(IRB), but did not meet the criteria for formal IRB-approval as
formulated by the Medical Research in Humans Act.

Development of the PPDL

The PPDL was developed based on literature research and clinical experi-
ences of physicians and nurses of two internal medicine wards. Potential
interventions for improving the handoff communication from hospital to
home were explored in focus group meeting with physicians and nurses
of the department of internal medicine. Research has shown that the most
effective approach of providing information to patients is combining
written and verbal information [20, 21]. The use of lay language in pa-
tient communication is essential to enhance compliance [22]. As a result,
the PPDL was designed to provide patient-centered communication. The
PPDL is a standardized document addressed to the patient and drafted in
a language that is understandable to the patient and his informal giver(s).
The goal of the PPDL was to educate patients and/or their informal care-
givers about problem-solving skills when discharged to home [23, 24].

The structure and contents of the PPDL were established through
an exploratory pilot phase on one (nursing) ward of the department of
internal medicine. This first version of the PPDL contained informa-
tion on the reason for admission, the treatment during hospitalization,
the course of the disease(s), possible sustained consequences or com-
plications and information on medication. The PPDL was written and
verbally explained to the patient or the informal caregivers of cogni-
tively impaired patients by medical interns before hospital discharge.
Residents mentored the medical interns during this process. All med-
ical interns and residents were trained in drafting and explaining the
PPDL and educated about issues related to health literacy [22]. The
training was performed on the job. A standard format for creating
the PPDL was provided on local computers on the wards (there was
no electronic medical record (EMR) during the pilot phase).

First phase of quality improvement

Before–after evaluation study
Implementation of the first version of the PPDL was initiated at two
medical wards. To evaluate the information provision, satisfaction and
content of this first version of the PPDL, the following study questions

Figure 1 Timeline of the development and implementation of the PPDL.

385A better informed discharge • Quality Improvement

were formulated. Does the implementation of the PPDL improve (i) ver-
bal and written information provision at hospital discharge and (ii) how
do patients value the content of the PPDL (post-implementation only)?

Participants of before–after evaluation study
Eligible patients had to meet the following criteria: (i) 18 years or
older; (ii) admitted at one of the four internal medicine wards for
more than 48 h and (iii) discharged home. Patients were mainly acute-
ly hospitalized with a broad range of internal medicine problems, such
as infections, gastro-intestinal diseases and kidney problems. The par-
ticipating internal medicine wards were staffed with nurses and physi-
cians. The wards had an important role in the professional education
and training of nurses and physicians. In the post-test phase only those
receiving the PPDL were included.

Data collection

Data collection on provision of discharge information was equal in the
before and after study group. A research nurse conducted structured
telephone interviews 1 week after discharge. The interview contained
questions regarding overall satisfaction with the information provided
upon discharge as well as whether the patients had been informed
about medication, complications and lifestyle. Furthermore, the inter-
view contained questions regarding by whom and how they had been
informed (verbal, written or both) and whether the information pro-
vided was deemed necessary and complete. Patient satisfaction with
the PPDL was measured in the after study group only. Patients were
asked to appraise the PPDL on a numeric rating scale (between 0
and 10; where 0 = not satisfied and 10 = totally satisfied).

Data analysis

Descriptive statistics were obtained on the patient characteristics
and information provision. We did not perform a formal sample size
calculation. As in the post-implementation phase only those receiving
the PPDL were included, and this was only 30% of the study sample,
we did not calculate statistical differences between the before and after
groups and present the data as descriptive.

Feasibility of the PPDL in daily practice

A process evaluation of the implementation of the intervention was con-
ducted. A focus group session with seven professionals (nurses, medical
interns and residents) was held to evaluate the acceptability and feasibil-
ity of the PPDL in daily practice, including barriers and facilitators.

Second phase of quality improvement

In the second phase of the QI we used the evaluations of the first phase
of quality improvement to improve the PPDL. In addition, we imple-
mented the PPDL in the EMR, which was evaluated by measuring the
number of PPDLs provided to patients at discharge. Pass rates were
calculated from this information after implementation of the interven-
tion. Furthermore, we developed hospital-wide policy and profession-
al education on discharge communication to alter patient-centered
communication during the handover process.

Results

First phase of quality improvement

Evaluation of pre-/post-test of PPDL implementation
A total of 141 patients participated in this study of which 111 patients
participated in the pre-implementation phase and 30 patients in the

post-implementation phase. The median age in both groups was
59 years and 48 versus 41% were male in the pre- and post-
implementation group (P = 0.67). Table 1 demonstrates about what
topics and how patients were informed at discharge. Most patients
of the pre-implementation group received verbal information about
their disease (90%) and treatment (90%), but rates of information
provision were much lower for medication (69%), complications
(47%) and lifestyle (36%).

After the implementation of the PPDL, the amount of patients re-
ceiving information on medication, complications and lifestyle was
improved on almost all domains, in particular in terms of medication.
More patients received a combination of written and verbal informa-
tion for the topics of medication and complications, respectively.

Overall, patients of the post-implementation group were satisfied
with the PPDL as indicated by a score of 7.3 (SD 1.0). Positive remarks
were made about the clear language of the PPDL, and patients viewed
it as a useful discharge service. Suggested improvements for the PPDL
included elaboration on complications and lifestyle, include a contact
person for questions and professionalize the layout.

Level of implementation
Four months after the implementation of the first version of the PPDL
on the two medical wards, the average level of implementation was
32%. On the first ward 76 of 173 discharged patients received the
PPDL upon discharge (44%). On the second internal medicine ward
the pass rate was 23%, 58 out of 249 patients received a PPDL.

Feasibility of the PPDL into daily practice

Overall, the nurses and physicians that participated in the focus group
session were positive about the PPDL and rated the initiative as import-
ant to improve the quality of care. The participants concluded that the
process of preparing and supervising the PPDL could be improved. Fur-
thermore, medical interns felt that explaining medical terms in under-
standable plain language was a difficult task. They also felt great
responsibility to ensure the correctness of the content and felt insecure
about this even though a resident supervised the PPDL. All professionals
involved noted that the electronic preparation and availability of the
PPDL within the EMR was a key component for successful implemen-
tation and secure the use of the PPDL into daily practice. On average,
interns spend 30 min preparing the PPDL, because an EMR was lacking.

Second phase of quality improvement

Establishing hospital-wide policy
An essential step for further implementation of the PPDL was develop-
ing a hospital-wide policy on handover summaries, to both the GP and
patients. Furthermore, the PPDL had to be integrated into the
hospital-wide policy on discharge procedures, which contained more
interventions related to the discharge procedure (e.g. discharge con-
versation, telephone follow-up) [25]. The development of a hospital-
wide policy was enhanced by the release of a patient manifest in our
hospital that contained 24 patient rights, including one on a personal
patient discharge letter [26]. The hospital-wide policy on handover
summaries was launched in April 2009. This document enabled us
to integrate the PPDL in the electronic patient record and contained
three versions of the PPDL: one for adults, one for teenagers and
one for parents of under-age children.

Integrating the PPDL in the electronic medical record

Next, to improve the feasibility of the PPDL, a project was started to
facilitate the preparation and availability of the PPDL within the

386 Buurman et al.

EMR. Standardization and quality of the content of the PPDL was en-
sured by using templates on common health conditions and predefined
texts on diagnosis, treatments, medication and lifestyle. Standard in-
formation on who to contact in case of frequently asked questions
was added, as well as the recommendation to bring the PPDL to
each visit with a medical professional. This electronic version of the
PPDL was made visible for all professionals in the hospital and
could be sent directly to the general practitioner at hospital discharge
(Appendix).

Integrating the PPDL and discharge conversation

into professional training

The results from the first implementation phase indicated that health-
care professionals perceived difficulties in using lay language and other
aspects related to health literacy in communicating with the patient
and their informal caregivers about discharge instructions. Further-
more, the PPDL was considered as an important educational tool
for addressing these issues for medical interns of the department of in-
ternal medicine. A 3-h communication-training program was devel-
oped by focusing on hands-on practice of discharge communication
skills and awareness of health literacy in cooperation with the depart-
ment of clinical psychology, who already provided communication
training before and during the internships. This training program
was provided before the internship. During the internship, training op-
portunities in which medical interns had to videotape an admission
interview were already in place. We added to this training the possibil-
ity of videotaping a discharge conversation instead. Furthermore, all
medical interns were obligated to write ten PPDLs during their
8-week internship, and these PPDLS were discussed with the professor
at the end of the internship. Throughout the entire process, the resi-
dent had the ultimate responsibility for the content of the PPDL and
authorized the PPDL before it was provided to the patient.

Evaluation of second phase of quality improvement

The interventions that were adjusted and implemented to improve the
feasibility of incorporating the PPDL into daily healthcare delivery
processes were measured again by focusing on the percentage of
PPDLs provided to patients at discharge. The evaluation was con-
ducted on four internal medicine wards during a 3-month period.
On these wards, the electronic version of the PPDL was implemented.
The implementation rate in this cycle varied between 14 and 71%
(Fig. 2a), with an average implementation rate of 51%, signifying an
important improvement when compared with the first cycle. There
were 2 weeks with low percentages of PPDLs provided; this was due
to a change in both residents and medical interns. They had to be in-
structed in writing and authorizing the PPDL in the electronic patient
record. If not considering these 2 weeks, the average implementation
rate was 57%. Moreover, we observed an improvement in the number
of discharge conversations that were held (Fig. 2b).

Discussion

The objective of this study was to improve the information provided to
patients at discharge. At the start of the quality improvement trajectory,
patients felt poorly informed at discharge from the hospital. As a result, a
PPDL was developed, implemented and evaluated. This PPDL consists of
a structured plain language discharge summary accompanied with a ver-
bal explanation of diagnosis, treatment, medication and recent changes in
medication, potential complications and lifestyle. Providing patients with
a PPDL increased the numberof patients who recalled that they received a
combination of verbal and written information. Integrating the PPDL in
the EMR, offering training to medical interns and integrating the PPDL in
hospital-wide discharge policies facilitated the implementation. With
these actions, we were able to achieve an implementation rate of 57%.
Moreover, the number of discharge conversations improved.

Table 1 Information needs of patients discharged from the hospital before and after implementation of the PPDL

Variables Before implementation
(n = 111)

After implementation
(n = 30)

Age (median, IQR) 59 (42–70) 59 (46–67)
Gender (% male) 47.7 41.4
Previous admission in the past 4 weeks (% yes) 26.1 27.6
Information on diagnosis and treatment
Do you understand the reason for your admittance to the hospital? (% yes) 90.2 93.1
Do you understand the treatment that was given? (% yes) 90.2 89.7

Information on medication
Did you use medication before admission? (% yes) 87.6 86.2
Where there changes in the medication regimen at discharge? (% yes) 64.0 75.9
Did you receive information on the medication that you should use after discharge? 69.0 84.6
How did you receive this information

Only verbally 54.2 13.0
Verbally and in writing 45.8 87.0

Information on complications
Did you receive information on possible complications that might occur after discharge? 46.8 67.9
How did you receive this information?
Only verbally 82.0 26.3
Verbally and in writing 18.0 73.7

Information on lifestyle advice
Did you receive information on changes in your life style, such as nutrition, movement
and wound care?

36.0 55.2

How did you receive this information
Only verbally 89.0 58.8
Verbally and in writing 11.0 41.2

IQR, interquartile range.

387A better informed discharge • Quality Improvement

Our study is not the first one that is performed on improving the
discharge from hospital to home. Several studies have demonstrated
the need for better discharge procedures [16, 17]. These studies mainly
focus on better information exchange between professionals and iden-
tified many deficits in the communication between the hospital and
general practitioner. With the PPDL we improved the information pro-
vision to patients at discharge. More patients actually indicated that
they received a combination of verbal and written information at dis-
charge. This is important, because the length of hospital stay has de-
creased dramatically in the past 10 years, yet more patients are
admitted with complex diseases and multiple morbidities [27, 28].
For this group of patients a combination of verbal and written infor-
mation on changes in treatment, new medication, what complications
can occur and when to contact the hospital is essential to self-manage
after hospital discharge and to recognize severe complications needing
medical care. Only providing information orally in for example a dis-
charge conversation is not sufficient; it limits the recall of information
[20–22]. The PPDL should be part of a bigger strategy to improve the
discharge from hospital to home. In our hospital, the PPDL is part of a
larger project on improving the discharge procedure [25].

Implementing the PPDL in daily practice proved to be challen-
ging. The level of implementation in the first cycle was on average
30%. Several reasons have been indicated; first, the lack of integration
of the PPDL into the EMR was a considerable barrier, since many
items that could have been predefined through the EMR had to be en-
tered manually. Moreover, the decision for discharge was often made
on the day of discharge. This time pressure was an important imple-
mentation barrier for creating and supervising the PPDL. In the second
quality improvement cycle we implemented many solutions for these
barriers. The medical interns received training to prepare the PPDL

and to held discharge conversations, the letters were supervised better,
the PPDL was integrated in the EMR and a hospital-wide discharge
procedure was implemented. Although there was an increase in the
number of PPDL provided at discharge, the implementation rate was
still 57%. We hypothesize that this is due to the extra handover that
has to be made for patients, instead of putting the patient and informal
caregiver at the center of the information handover. It would be well
possible to use the PPDL as a formal handover for the patient and sent
it to the GP as well. In the end, the patient is the only continuous factor
in the transition from hospital to home. This would make the PPDL
wider applicable and reduces the number of handovers that have to
be written. Moreover, for specific patient groups (e.g. some surgical
procedures) standardized letters could be prepared, where only limited
amount of tailoring needs to be performed.

Our study has several limitations. We used a non-controlled be-
fore–after design, which is not the most strong evaluation design
and did not collect information on health literacy, education and
socio-economic status. Therefore, the results should be interpreted
with caution. We did not perform a formal sample size calculation,
as the project started as a quality improvement trajectory. The study
was a small-scale initiative limited to only four medical wards in
one university teaching hospital in the Netherlands, and therefore
the generalizability and applicability of the PPDL in other patient po-
pulations and general hospitals needs further study. More knowledge
is needed on the specific advantages and feasibility of the PPDL for cer-
tain age-groups and patients with multiple morbidities. Additional re-
search, in a broader patient population and in a multi-center context,
is needed to establish external validity and study long-term effects on
patient empowerment and AEs in the post-discharge phase. Currently,
the PPDL is adopted by the Senior Friendly hospital concept and hos-
pitals in the Netherlands have to demonstrate whether they provide a
PPDL to patients.

In conclusion, the PPDL improved the provision of verbal and
written information at discharge. Education of interns, residents and
staff, standardization of content of the PPDL, integrating the PPDL
into the EMR and hospital-wide policy to promote the PPDL were
key success factors for feasible implementation. Further research
should focus on the impact of the PPDL on adverse health outcomes.

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Figure 2 (a) Percentage of patients that received a PPDL at discharge from the

hospital. (b) Percentage of patient that had a discharge conversation prior to

discharge.

388 Buurman et al.

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Appendix

An example of a personalized patient discharge
letter (with a hypothetical patient)

AMC
Meibergdreef 9
Postbus 22660
1100 DD Amsterdam
www.amc.nl

Amsterdam, November 15th 2011

Patiëntnr : 1234567
Date of birth : 13-11-1934
General Practitioner: Dr. Hansen

Concerns: personalised information upon discharge
Dear Mrs. Jansen,

Hospitalization can be a stressful event in which a lot of information is
provided to you. In this personalised discharge letter, we provide you
with the necessary information you need at home. We advise you to
bring this personalised discharge letter when visiting your general
practitioner or specialist. Your general practitioner will receive a
copy of this letter.

Admission:
You were admitted in the AMC from 19-10-2011 to 12-11-2011
and resided at F7zuid, general internal medicine & gastro-intestinal
diseases
Telephone number: 020-5666666

Reason of admission:
Insufficient intake because your bowel is very short. You were unable
to take enough food and take the necessary ingredients. It was follow-
up treatment after discharge from the OLVG hospital.

The medical term for this disease is:
Insufficient intake/resorption due to short bowel syndrome (as a result
of therapy-resistent Crohn’s disease).

Your important medical background
You were diagnosed with Crohn’s disease in 1992. Since then you have
had multiple resections of the bowel (subtotal colectomie and multiple
resections of small intestine), complicated with fistulae. Your last oper-
ation was in August this year in the OLVG, where 50 cm of intestine was
removed. Now there is approximately 120 cm of small intestine left.

Allergies reported: none
During your hospital stay the following diagnostic procedures were
carried out
We did several bloodtests, to see whether there were signs of infection in
the blood and to see whether there were any nutritional deficiencies. The
first days there were some signs of infection seen, but these values de-
creased after a few days. A few slight electrolyte deficiencies were seen,
but were corrected soon after start of the total parenteral nutrition (TPN).

We made some cultures of the pus from the rectum and from the
wounds on the belly. Some bacteria were found, but it was not neces-
sary to use antibiotics.

We also performed an endoscopy, on which the small intestine
seemed healthy, not inflamed and no fistulae were seen. We did a rectal
examination with a scope, but we could not see where the pus was com-
ing from, since the rectum was very narrow after just a few centimetres.

We tried to do a MR-enterogram to make sure there were no fistu-
lae under the wounds on the belly, but it was not possible for you to
drink all the contrast fluid as it made you very nauseous.

During your hospital stay the following treatment was started
We have placed a TPN-line, first in your left upper arm, later in the
jugular vein, so you could be fed intraveneously. This could be tem-
porarily, the small intestine might adapt to the fact that there isn’t
much bowel left. But for now it is important to improve your nutritional
status and your general condition.

You received a training from the nurses so you’ll know how to take
care of the TPN-line and how to feed yourself with it. We also started
medication (Sintrom) to prevent blood clots in your veins, which can

389A better informed discharge • Quality Improvement

www.amc.nl

occur in people with an intravenous line, especially in combination
with active IBD.
We nursed the wounds on the belly, to let them heal properly. The in-
flammation had decreased by the time you went home.

Summary of the hospital stay:
You were admitted to our ward because of insufficient intake/resorption
of food, due to a short bowel in combination with your therapy-resistent
Crohn’s disease.

We monitored the signs of infection in your blood, which had de-
creased after a few days in the hospital. We gave you an TPN-line so
you can be fed intraveneously and we trained you to take care of the
line and feed yourself with it at home. Since the small intestine seemed
healthy on the endoscopy, we lowered the dosage of Humira to 40 mg
every other week, instead of 40 mg every week. The Lanvis was stopped
altogether, since you felt you did not benefit from taking it. We started
Sintrom in order to prevent the forming of blood clots in your veins, due
to the TPN-line. In the beginning you will have to go to the Thrombosis
Service (Trombose Dienst) regularly, to achieve the right dosage for you.

For now it is important to improve your nutritional status and your
general condition. Dr. One will be the doctor in the outpatient clinic
who will check up on how the TPN is going and if alterations will have
to be made in your nutrition. Dr. Two will be your IBD doctor in the
outpatient clinic, together you will think of what will be the next step
once you’ll have strengthened.

Important information for you to take care of at home
Once you experience fever, increased abdominal pain or blood/pus in
the stoma bag along with your stools, please contact the outpatient
clinic and ask for Dr Two, telephone number 020-5666666

Advice for food and fluids
You will receive TPN for now, but if possible it is good to eat as well.

Advice for daily activities
You can resume your daily activities as much as is possible for you.

The following appointments are made with you
You have got an appointment with Dr. Two from the IBD outpatient
clinic on the December 20th at 14.45u.

You have got an appointment with Dr. One, the TPN-doctor, on De-
cember 20th at 15.30u.

If you have any questions

Contact with the hospital
Within 48 hours after discharge a nurse of the ward you were admitted
on will contact you, to see if you have any questions. The nurse will
contact the medical resident if necessary

Contact with the outpatient department
If you have an appointment scheduled with the outpatient department,
please contact the outpatient department if your question cannot wait
until the appointment. Telephone number 020-5666666

Contact with your general practitioner
If you do not have a scheduled appointment at the outpatient depart-
ment, than contact your general practitioner in case you have ques-
tions. If any problems occur out of office hours, please contact the
central emergency post related to your general practice.

Questions related to medication use
If you have any questions on the use, effects or side effects of medica-
tion, contact your general practitioner. The general practitioner will
contact the hospital if necessary.

Do you have medication that is not prescribed anymore? Deliver
these medications at your pharmacy.

Is your medication finished? Than call your general practitioner for
a new receipt.

Frequently asked questions related to discharge and care
On the website of the AMC, you will find information on the frequent-
ly asked questions. www.amc.nl/discharge

With kind regards,

Marije de Jager, medical intern

Harro Klein, medical resident

390 Buurman et al.

www.amc.nl/discharge

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September-October 2016 • Vol. 25/No. 5 297

Jessica R. Sherman, DNP, RN-BC, is Clinical Assistant Professor, Department of Nursing,
College of Nursing and Health Sciences, University of Vermont, Burlington, VT.

An Initiative to Improve Patient
Education by Clinical Nurses

A
fter hospitalization, patients
need to understand how to
care for themselves at home.

One of the most important things
nurses can do to improve outcomes
is to educate patients about their
self-care needs before discharge
(London, 2016). Nurse educators
must prepare clinical nurses through
continuing education, in-service
programs, and staff development to
improve and maintain their teach-
ing abilities (Bastable, 2014). Accord –
ing to Lau-Walker, Landy, and
Murrells (2016), as patient-centered
education be comes more wide-
spread, the need increases to support
healthcare staff in confidence and
satisfaction with delivery of patient
education. Bastable (2014) suggested
nurses must be equipped to provide
effective education that meets the
needs of individuals and groups
from diverse backgrounds with dif-
ferent needs. Reiter (2014) further
noted the patient’s preconceived
views are influenced by age, culture,
learning ability, and language, which
need to be considered when individ-
ualizing education. Additionally,
nurses who assess patient education
requirements swiftly and modify
educational efforts to the patient are
invaluable members of the health-
care team.

Literature Review
A literature search for 2011-2016

was performed using CINAHL,
Ovid, and PubMed databases. Key
search words included patient educa-
tion, nurse and patient education, self-
care, teaching modalities, and learner
assessment. Because the nursing lit-
erature had little information on

methods for improving patient edu-
cation or outcomes of patient edu-
cation, an interprofessional search
was conducted to determine if edu-
cating healthcare personnel about
a structured teaching approach
would improve education delivery
as well as patient outcomes.

Wilhelm and Petrovitch (2011)
developed a structured anticoagula-
tion teaching program to improve
education services to inpatients
before discharge with anticoagula-
tion therapy. The setting included
three facilities as part of an eight-
hospital system: a large teaching
hospital, a women’s hospital, and a
rehabilitation center. This educa-
tional program, which included a
didactic presentation, focused on
standardized counseling for oral
and injectable anticoagulants. It
was provided to pharmacy students
and residents. The rationale behind
developing such an educational
program was a lack of patient edu-
cation regarding anticoagulation
therapy by pharmacists. After phar-
macy students and residents were
educated, they were placed on a
teaching service responsible for
anticoagulation patient education.

Using a retrospective review of
387 inpatient charts, authors exam-
ined the impact of the anticoagula-

tion education teaching service on
the rate of education being delivered
and rate of readmission (Wilhelm &
Petrovitch, 2011). Patients had been
discharged home with a prescrip-
tion for warfarin (Coumadin®) or
low molecular weight heparin dur-
ing a 5-month period before and
after implementation of the teach-
ing service. Authors found signifi-
cant improvement in anticoagula-
tion education rates after implemen-
tation of the program (p<0.0001). Prior to implementation of the edu- cational program, 169 patients received education; 218 patients received education after the pro- gram began. No significant differ- ence was found in anticoagulant- related 30-day readmission rates of patients who received education versus those who did not. However, a significant difference was found in the 60-day readmission rate for patients who did not receive the teaching service anticoagulation education (50.5% vs. 37.9%, p=0.0141). This study concluded ini- tiatives in which healthcare person- nel are provided education on methods to deliver patient educa- tion can result in positive outcomes.

Warden, Freels, Furono, and
Mackay (2014) also developed a
structured educational approach

Jessica R. Sherman

Clinical nurses play a vital role in the delivery of patient education.
The focus of the project described in this article was to promote a
standard of practice that would improve nurses’ ability as effective,
efficient patient educators.

Instructions for Continuing Nursing Education Contact Hours appear on page 300.

September-October 2016 • Vol. 25/No. 5298

with pharmacy students. Authors
used a quasi-experimental design to
measure the effect of a pharmacist-
managed program for heart failure
medication education and discharge
instruction on 30-day readmission
rates. They found a significant in –
crease in discharge education and
reduced 30-day hospital admissions
in comparison to the control group
(p=0.007).

Lau-Walker and co-authors (2016)
evaluated the impact of integration
of a Personalized Patient Education
Protocol (PPEP) into an existing
post-myocardial infarction care
pathway. Nurses received training
on use of the PPEP along with a
workbook for patients. During a 2-
month pilot, they practiced using
the PPEP tool during patient dis-
charge and were debriefed by the
researcher on its use. Nurses also
provided feedback to researchers on
more effective use of the tool. Pat –
ients with a confirmed diagnosis of
myocardial infarction in a London
hospital were invited to participate
in a longitudinal patient survey.
They were asked to complete ques-
tionnaires before discharge and 3
months after discharge. Based on
information about patients’ illness
beliefs and expectations from the
first questionnaire, nurses discussed
and assisted patients to make con-
nections between their individual
illness perceptions and specific rec-
ommended health promotion beha –
vior to manage illness better. A PPEP
workbook also was provided to the
patients, with its purpose explained.

Authors found a significant
change at 3 months (p=0.021), sug-
gesting patients had a better under-
standing of their illness (Lau-Walker
et al., 2016). Patients also reported
significant improvement in their
general health (p=0.041), and 59%
indicated the PPEP workbook was
useful. In addition, nurses integrat-
ing PPEP into the discharge process
were interviewed. They identified
their initial reluctance to incorporate
the PPEP into their practice. How –
ever, use of the PPEP allowed unique
insight into patients’ perceptions of
their own health

These studies suggested nurses

and other healthcare personnel
may need further instruction on
providing structured, effective pa –
tient education. They also support-
ed the premise that delivery of
patient education increases and
outcomes improve when providers
receive this education. A need exists
for the patient education curricu-
lum developed for this project to
improve clinical nurses’ ability as
educators.

Improvement Needs
The site for this quality improve-

ment project was an academic med-
ical center in New England. The
organization had no practice stan-
dard for patient education. Central
and unit-based nurse educators
were responsible for educating nurs-
ing staff rather than patients. The
hospital also did not employ spe-
cialty nurses dedicated to imple-
menting patient education, which
was the responsibility of clinical
nurses. The purpose of this project
was to provide nurses with a struc-
tured approach to effective, effi-
cient patient education.

Participants were clinical nurses
from two inpatient medical-surgical
units. The chosen inpatient nursing
units were selected as the first two

units to schedule their clinical nurs-
ing staff annual education days in
2013.

Quality Indicators and
Data Collection

The clinical question for this
project was as follows: Will clinical
nurses demonstrate improvement
in knowledge as well as perform-
ance during a simulated patient sce-
nario after completing a curriculum
designed to promote effective and
efficient patient education through
the use of key steps to education?

The Plan Do Study Act (PDSA)
cycle was used to guide this quality
improvement project (Harris, Rous –
sel, Walters, & Dearman, 2011).
Assessment tools included a pretest-
posttest (see Table 1) and pre-post
simulation performance checklist
(see Table 2). These tools were used
to determine if an increase in base-
line knowledge and performance
occurred after RNs completed the
patient education curriculum. They
were developed by the project
leader to connect directly with
learner curriculum objectives.
Content validity was established by
experts in nursing, nursing educa-
tion, and nursing simulation. Tools
were edited based on expert recom-

TABLE 1.
Pretest-Posttest Questions

1. The purpose of assessing a patient’s learning needs is to:
2. All are a correct example of setting mutual goals/objectives for the educa-

tional lesson with your patient except:
3. You have assessed your patient’s learning needs and determined

goals/objectives of the lesson. Your patient would like to know more about
drain care and is a “hands-on” (kinesthetic) learner. What teaching method
would be most appropriate to use with your patient?

4. “Teach-back” is a form of:
5. How do you know the patient has gained the necessary knowledge to

perform self-care safely at home?
6. If a patient has demonstrated or explained a detail from your educational

lesson incorrectly, you would first:
7. Health literacy means:
8. Effective patient discharge education provides the patient with:
9. You have determined your patient is an auditory learner. What would be the

best teaching tool to explain Lovenox® administration?
10. Patient education is:

September-October 2016 • Vol. 25/No. 5 299

mendations and returned for review
until all experts indicated the tools
represented a connection to the
learner curriculum objectives. The
pretest-posttest consisted of 10 mul-
tiple-choice questions. The simula-
tion performance checklist includ-
ed six performance objectives (meets
to does not meet). Reliability of the
tools could not be established dur-
ing data analysis because partici-
pants were not matched to them-
selves for activities before and after
education.

The patient education curriculum
was reviewed, edited, and enhanced.
Test questions that did not demon-
strate improvement were evaluated
and modified for future use. Nursing
specialty simulation scenarios also
were designed and added to the cur-
riculum. The revised, enhanced
patient education curriculum was
given to the organization’s Director
of Nursing Education and Research
for distribution to all nurse educa-
tors. The nurse educators integrated
the patient education curriculum
into professional development for
clinical nurses throughout the
organization, spreading and sustain-
ing a standardized approach to
patient education.

Action Plan and Evaluation
This project used a one-group

pre-post design, with the designed
patient education curriculum as the
intervention. The curriculum focus –
ed on providing nurses with key
steps to standardize delivery of
patient education and allow in –
creased, improved patient educa-
tion delivery. These key steps
focused on assessing the learner,
setting mutual learning goals and
objectives, using appropriate teach-
ing modalities, and evaluating with

teach-back. The 15-20 minute pres-
entation also offered ways to imple-
ment the key steps.

The project occurred during eight
annual RN education days January-
May 2013, with 85 nurses invited to
participate. Before implementation,
the project leader ex plained what
could be expected in the pretest-
posttest and pre-post simulation.
Signed consent included agreement
to maintain confidentiality of the
exercises and to be video recorded.
RNs who were participating in new
graduate orientation were excluded
from participation.

Participating RNs first completed
the pre-test, after which they
reviewed the simulation scenario
and then entered the simulation.
The scenario addressed a patient
who was ready for discharge and
needed education on a topic specif-
ic to the participating RN’s unit
(e.g., wound care, neutropenia).
The simulation scenario used a
standardized patient (SP) and was
ended automatically if the partici-
pant reached 15 minutes. After the
simulation, RNs received instruc-
tion in the patient education cur-
riculum from one of two nurse edu-
cators trained by the project leader.
RNs who chose not to participate in
the project also received the patient
education content. Immed iately
after the presentation, participants
completed the posttest. RNs were
allowed to review the same simula-
tion scenario but complete it with a
different SP. Again, simulation was
ended for anyone reaching 15 min-
utes in the scenario. After comple-
tion of the final simulation, the SP
stepped out of character to debrief
the RN. The entire participant
group then reconvened for a group
debriefing by a certified healthcare
simulation educator.

No identifying information was
collected during the pretest-post –
test. To maintain anonymity, simu-
lations were recorded and viewed
by two additional nurse educators
who did not have direct contact
with the participating nursing
units. Nurse educators viewed each
simulation using the simulation
performance checklist. All tests,
recordings, and simulation per-
formance checklists were se cured in
a locked office.

All participant answers were
entered into an Excel (Microsoft,
Inc.; Redmond, WA) document.
Pretest and posttest averages were
compared by participating unit and
as a group. Individual test scores
and simulation performance check-
lists were compared as an overall
test average. SPSS Statistics 21 soft-
ware (IBM Corp.; Armonk, NY) was
used to determine results of the
Pearson Chi-Square test, Levene’s
Test for Equality of Variance, and a
t-Test for Equality of Means. The
Pearson Chi-Square test also was
completed on the pre-post simula-
tion performance checklist data,
with a Kappa statistic to determine
inter-rater reliability.

Results
The author collected 66 pretests

and 66 posttests. Comparison of
participating units from pretest to
posttest demonstrated an improve-
ment in knowledge (pretest average
83%, posttest average 89%). All but
three questions demonstrated
improvement between tests; they
focused on assessing learners with
use of appropriate teaching modali-
ties, clarifying incorrect teach-back,
and defining health literacy. The
range of improvement was 2%-
16%. Three questions demonstrated
statistical significance (p=0.001,
0.026, and 0.032) with the Pearson
Chi-Square test: assessment of the
learner (question #1), validation of
patient learning (#5), and a defini-
tion of patient education (#10).
Levene’s Test for Equality of
Variance result (p=0.010) illustrated
statistically significant variability
between the two tests. A t-Test for
Equality of Means result (p=0.003)

An Initiative to Improve Patient Education by Clinical Nurses

TABLE 2.
Simulation Performance Checklist Objectives

Learner will:
1. Demonstrate the ability to assess the patient’s preferred learning style.
2. Validate with the patient the topic/goals/objectives of the educational session.
3. Use appropriate teaching modalities based on the learning needs assessment.
4. Use teach-back method/questioning to evaluate the patient’s understanding of

educational content.

September-October 2016 • Vol. 25/No. 5300

demonstrated a significant differ-
ence between the two tests that was
likely a result of the intervention
(Burns & Grove, 2012).

Forty simulations were viewed.
The difference in participant num-
bers between the test and simula-
tion is multifaceted. One group of
RNs was incapable of completing
the simulation portion of the proj-
ect on their education day due to
room scheduling conflicts. A few
participants decided not to com-
plete the second simulation, but did
complete both tests. Finally, the
project leader omitted some simula-
tion data provided by the nurse
educators who viewed and collected
data on the simulations because
they were unclear.

Each simulation performance
checklist objective demonstrated
improvement (pretest to posttest
range 16%-31%). Three objectives
dem onstrated statistical signifi-
cance (p=0.010, 0.005, 0.005) on a
Pearson Chi-Square test.

Limitations
The small sample and the unifo-

cal project setting were limitations
of the project. Reliability of the tools

was not determined statistically
because tools were not matched to
participants; in other words, a par-
ticipant’s pretest or pre-simulation
was not compared to his or her
posttest or post-simulation. Another
limitation was completion of the
pretest-posttest by one group of
nurses who were unable to complete
the simulations due to a scheduling
conflict within the simulation
department. Finally, inter-rater relia-
bility between the two nurse educa-
tor observers was poor. Only two
objectives demonstrated inter-rater
reliability when a Kappa statistic was
completed: educators demonstrated
inter-rater reliability focused on set-
ting mutual learning goals/objec-
tives, and continual reassessment of
learning using teach-back until
learner comprehension occurred.

Nursing Implications
The patient education curriculum

will contribute to provision of effec-
tive, efficient education by clinical
nurses within the organization. The
development of a standardized
patient education ap proach for clini-
cal nurses promoted improvement in
patient education practices, which in

turn may promote a patient’s ability
in self-care and improve patient out-
comes. Outcomes of this project sup-
ported research by Wilhelm and
Petrovitch (2011), Warden and col-
leagues (2014), and Lau-Walker and
co-authors (2016) in which educat-
ing healthcare professionals on a
structured approach increased educa-
tion encounters and improved
patient outcomes.

Patient education is a required
component for successful patient
outcomes. The clinical nurse has a
unique opportunity to impact pa –
tient outcomes through patient
education. Barriers to patient educa-
tion included lack of motivation,
skill, confidence, and competence.
While educating patients has been
an essential part of nursing practice
for many years, most nurses be –
lieved they did not have formal
preparation to be successful at the
role as educator (Bastable, 2014).
This project was developed to pro-
vide nurses a standardized approach
and increased knowledge to over-
come barriers related to knowledge,
preparation, and confidence, in
turn improving their patient educa-
tion practices.

continued on page 333

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An Initiative to Improve Patient Education by Clinical Nurses

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Learning Outcome
After completing this learning activity, the learner will be able to
recognize how a structured approach improves patient education
practices.

The author(s), editor, editorial board, content reviewers,
and education director reported no actual or potential
conflict of interest in relation to this continuing nursing
education article.

This educational activity is jointly provided by Anthony J.
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September-October 2016 • Vol. 25/No. 5 333

Improve Patient Education
continued from page 300

Conclusion
To promote better patient health

outcomes, clinical nurses need to be
involved increasingly with patient
education. However, they require
support and resources in their role as
patient educators to be successful
(Lau-Walker et al., 2016). Organi –
zational support, such as the curricu-
lum used in this project, promotes
increased knowledge and confidence
in clinical nurses as they contribute
to improved health outcomes
through patient education.

REFERENCES
Bastable, S.B. (2014). Nurse as educator.

Principles of teaching and learning for
nursing practice (4th ed.). Burlington,
MA: Jones & Bartlett Learning.

Burns, N., & Grove, S.K. (2012). The practice
of nursing research: Appraisal, synthe-
sis, and generation of evidence (7th ed.).
St. Louis, MO: Saunders Elsevier.

Harris, J.L., Roussel, L., Walters, S.E., &
Dearman, C. (2011). Project planning
and management. A guide for CNLs,
DNPs, and nurse executives. Sudbury,
MA: Jones & Bartlett.

Lau-Walker, M., Landy, A., & Murrells, T.
(2016). Personalised discharge care
planning for postmyocardial infarction
patients through the use of a
Personalised Patient Education Protocol
– implementing theory into practice.
Journal of Clinical Nursing, 25(9-10),
1292-1300. doi:10.1111/jocn.13177

London, F. (2016). No time to teach: The
essence of patient and family education
for health care providers (2nd ed).
Atlanta, GA: Pritchett & Hull Associates,
Inc.

Reiter, K. (2014). A look at best practice for
patient education in outpatient spine sur-
gery. Association of Perioperative
Registered Nurses Journal, 99(3), 376-
384. doi:10.1016/j.aorn.2014.01.008

Warden, B.A., Freels, J.P., Furuno, J.P., &
Mackay, J. (2014). Pharmacy-managed
program for providing education and dis-
charge instructions for patients with heart
failure. American Journal of Health-
System Pharmacy, 71(2), 134-139. doi:
10.2146/ajhp130103

Wilhelm, S.M., & Petrovitch, E.A. (2011).
Implementation of an inpatient anticoag-
ulation teaching service: Expanding the
role of pharmacy students and residents
in patient education. American Journal of
Health-System Pharmacy, 68(21), 2086-
2093. doi:10.2146/ajhp10065

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PHARMACOEPIDEMIOLOGY AND PRESCRIPTION

Improved quality in the hospital discharge summary
reduces medication errors—LIMM: Landskrona Integrated
Medicines Management

Anna Bergkvist & Patrik Midlöv & Peter Höglund &
Lisa Larsson & Åsa Bondesson & Tommy Eriksson

Received: 17 December 2008 /Accepted: 1 June 2009 /Published online: 26 June 2009
# Springer-Verlag 2009

Abstract
Purpose We have developed a model for integrated
medicines management, including tools and activities for
medication reconciliation and medication review. In this
study, we focus on improving the quality of the discharge
summary including the medication report to reduce medi-
cation errors in the transition from hospital to primary and
community care.
Methods This study is a longitudinal study with an
intervention group and a control group. The intervention
group comprised 52 patients, who were included from

March 2006 until 31 December 2006, with a break during
summer. Inclusion in the control group was performed in
the same wards during the period 1 September 2005 until
20 December 2005, and 63 patients were included in the

control group. In order to improve the quality of the
medication report, clinical pharmacists reviewed and gave
feedback to the physician on the discharge summary before
patient discharge, using a structured checklist. Medication
errors were then identified by comparing the medication list
in the discharge summary with the first medication list used
in the community health care after the patient had returned
home.
Results By improving the quality of the discharge
summary, patients had on average 45% fewer medica-
tion errors per patient (P=0.012). The proportion of
patients without medication errors was 63.5% in the
control group and 73.1% in the intervention group.
However, this increase was not significant (P=0.319).
Patients who used a specific medication dispensing system
(ApoDos) had a 5.9-fold higher risk of suffering from
medication errors than those without this medication
dispensing system (P<0.001). Conclusion Review and feedback on errors in the discharge summary, including the medication report and a correct medication list, reduced medication errors during the transfer of information from hospital to primary and community care.

Keywords Elderly. Hospital discharge . Inpatients .

Medication errors . Medication reconciliation .

Medication report

Introduction

In the elderly, the risk of medication errors increases with
the number of home medications when admitted to or
discharged from hospital [1]. Medication errors can lead to

Eur J Clin Pharmacol (2009) 65:1037–1046
DOI 10.1007/s00228-009-0680-1

A. Bergkvist (*)
Hospital Pharmacy, University Hospital MAS,
205 02 Malmö, Sweden
e-mail: anna.bergkvist@med.lu.se

A. Bergkvist: Å. Bondesson : T. Eriksson
Department of Clinical Sciences in Lund, Lund University,
Lund, Sweden

P. Midlöv
Department of Clinical Sciences in Malmö – General
Practice/Family Medicine, Lund University,
Lund, Sweden

P. Höglund
Department of Clinical Pharmacology, Lund University Hospital,
Lund, Sweden

L. Larsson : Å. Bondesson : T. Eriksson
Hospital Pharmacy, Lund University Hospital,
Lund, Sweden

severe consequences for the patient, and 20–30% of
medication errors have been assessed as potential adverse
drug events [2]. A review article reports that of the
medication errors identified, 11–59% were thought to be
of clinical importance [3]. Various types of medication
errors are frequent in hospitals [4, 5] and in the interface
between care levels [6–16]. Insufficient quality in the
transfer of information on a patient’s medications has
recently been highlighted as one of the most important
problems in health care, and international and national
programs have been developed for information and help
[16]. According to the Institute for Healthcare Improve-
ment, poor communication of medical information at
transition points is responsible for as many as 50% of all
medication errors and 20% of adverse drug events in the
hospital [11].

In order to provide appropriate and correct treatment for
the patient and ensure good patient safety, effective
communication between the different care levels is crucial.
In Sweden, as in many other parts of the world, each care
level does not always possess the complete information on
a patient’s medical history, as many care units have their
own medical records. The risk of medication errors
occurring, and thus morbidity as a consequence of
medication errors, is therefore high. Risks of reduced
patient safety as a consequence of poor communication
are well documented and reported. A step towards
improved patient safety is harmonising the use of medical
records so that the hospital and primary care can access the
same information. Recently this has been introduced in
Sweden and is now used by 4 of 21 counties [17].

A previous study made by our research group, which
addressed medication errors caused by insufficient
transfer of information when changing care level,
showed that information on every fifth medication was
transferred erroneously [18]. At admission to hospital, 29
of 34 patients had at least one medication error and
corresponding results at discharge from hospital to
community health care showed 19 of 35 patients with
errors [18]. As a consequence of the study, a discharge
summary with a medication report was developed at Lund
University Hospital to reduce transfer errors. This
document is written for the patient and contains the
following [19]:

& General information (reason for admission to hospital,
planned follow-up)

& Medication report (a section with information on
changes that were made to the medication therapy and
reasons for these changes)

& Medication list (a list of current medications, dosages
and indications for each medication)

At discharge, the document is given to the patient and, if
applicable, sent to the community health-care provider and
the patient’s general practitioner.

The first evaluation of this medication report was made
at Lund University Hospital and showed that medication
reconciliation using a medication report significantly
reduced both the total number of medication errors as well
as the number of medication errors with moderate and high
risk for clinical consequences [19]. The medication report
has also been shown to significantly reduce morbidity and
thus the need for medical care due to medication errors in
the elderly [20]. However, the study did not evaluate the
content and correctness of the medication report, so there is
room for further improvement in the process, which is the
basis for this study.

This study is part of an integrated medicines manage-
ment investigation (the LIMM study), in which a multi-
intervention process approach to drug therapy was used.
This has been shown to improve the quality and appropri-
ateness of the prescription of medication to the elderly [21].
The aim of this study was to investigate whether the
process improves the quality of the discharge summary and
if this process development also reduces medication errors
when patients are discharged from hospital.

Methods

Study design

This study is a longitudinal study with an intervention group
and a control group. Patients in the control group were
included at the same wards prior to the intervention period.

The ethics committee at Lund University had no
objections to the study, and it was performed in accordance
with Swedish ethics legislation and the Declaration of
Helsinki.

Setting and study population

Patients admitted to the Department of Internal Medicine at
Landskrona Hospital in the county of Skåne in southern
Sweden were the source for inclusion. The clinic comprises
three wards with 61 beds in total. The hospital and the
primary care clinics do not have access to the same medical
records.

Quality improvement of the information in the discharge
summary

Patients eligible for inclusion were identified from the
intervention group in the multi-intervention study [21].

1038 Eur J Clin Pharmacol (2009) 65:1037–1046

Inclusion criteria for the multi-intervention study were
patients 65 years or older and living in the towns of
Landskrona or Svalöv, including patients discharged to the
community health care as well as those without help from
the community health care. Patients were included from 1
March 2006 until 31 December 2006, with a break during
summer (from 1 June 2006 until 31 August 2006).
Inclusion was done continuously and systematically during
the study period.

Medication errors when discharged from hospital
to community health care

The same intervention group was used as for “Quality
improvement of the discharge summary”, with the addi-
tional criteria that the patient had to be discharged to
community health care.

Patients in the control group were included from 1
September 2005 until 20 December 2005.

At inclusion, the patient received oral and written informa-
tion about the study from the pharmacist and at acceptance,
the patient was asked to give written consent to participate in
the study. When it was not possible to communicate with the
patient, a next of kin was asked instead. Patients in terminal
stages of their disease were excluded for ethical reasons.

Intervention

During the intervention period, the pharmacists took
part in the daily work at the three wards and performed
structured interventions in order to increase the appro-
priateness of the drug treatment [21]. Several interven-
tions were performed by the pharmacists. At admission,
medication reconciliation was performed in order to
identify the correct patient medication list, problems with
handling, knowledge, compliance and attitudes towards
the drug treatment. The patient’s potential drug-related
symptoms were checked. A medication review was
performed in order to further identify drug-related prob-
lems and inappropriate drug use. Based on identified
problems, a systematic medication care plan was created
in which all changes to the medication therapy were noted.
The care plan was updated continuously and was decided
on by the team. The pharmacists took an active role in
patient information and education, based on specially
developed drug information leaflets, with focus on new
medications.

A physician completed the discharge summary
(Appendix 1), including the medication report and a
medication list, at the day of discharge, and the
pharmacist then evaluated the document according to a

developed checklist (Appendix 2), with focus on correct-
ness of the medication report and the medication list. The
pharmacist used the medication interview, the care plan,
as well as other medical records from the hospital stay,
to evaluate the information in the discharge summary.
If information was lacking or was incorrect, the
pharmacist discussed this with the physician who was
then able to adjust the document before the patient was
discharged.

Measures

Quality improvement in the information in the discharge
summary

Data were collected on discrepancies found between the
information in the discharge summary and the systematic
medication care plan as well as other medical records from
the patient’s hospital stay. The checklist (Appendix 2) was
developed and accepted at Lund University Hospital as a
standard and a tool to measure and follow-up on important
features and errors in the writing of the discharge summary.
For the medication report, the standard was that all final
changes in medication made during the hospital stay and
the reason for them should be documented. For the
medication list, a complete list of all current medications
and the indication, reason, or disease state should be
documented. A total score of the quality, including general
information, could also be calculated.

In order to study discrepancies that were considered
more important than others, information was collected on
which discrepancies the physicians chose to adjust or not.

Medication errors when discharged from hospital
to community health care

Discharge summaries were written by a physician for all
patients, but only evaluated by a pharmacist during the
intervention period. The medication list in the discharge
summary from the hospital was compared with the first
medication list used by the community health care after
discharge in order to study whether the transfer of information
was done correctly. Some patients received medications from
a specific medication dispensing system (ApoDos), in which a
regional pharmacy ApoDos dispensing unit prepared the
dosages and provided the patients with a complete list of all
medications used by the patient. Other patients did not use this
system and for them, the community health care had
medication lists that they filled out manually.

The same definition of medication error and the same
checklist for documenting the errors as in previous studies
were used [18, 19]. The definition states that a medication

Eur J Clin Pharmacol (2009) 65:1037–1046 1039

error is any error in the process of prescribing, dispensing
or administering a drug, whether there are adverse
consequences or not [22]. In this study, we focused on the
discrepancies in the medication reconciliation discharge
process, and a medication error was defined as occurrence
of one of the following discrepancies together with the lack
of documentation to indicate that the change in the
medication therapy was done deliberately.

& A medication was missing in the medication list from
the community health care.

& A medication had been added to the medication list
from the community health care.

& The total dosage over 24 h had been changed in the
medication list from the community health care.

Generic substitution of a medication was not considered
an error in the reconciliation process.

When the patient was transferred to the community
health care, nurses were asked to send in the first
medication list used after the patient arrived. If no
medication list was received from the community health
care, reminders were sent out repeatedly. Identification of
medication errors was done prospectively in both groups.
Two pharmacists evaluated the transfer of information
independently, and their evaluations were compared and
consensus was reached.

Study size calculation

In a previous study in Landskrona (in which the medication
report was not used), 46% of the patients had no
discrepancies between their medication list at discharge
and their medication list after returning to community
health care [18]. Later on, in a study at the University
Hospital in Lund (USiL) in which the medication report
had already been in use for 6 months, 66% of the patients
had no medication errors when transferred from hospital to
community health care [19]. We assumed that the results
from the study at USiL were similar to the baseline in this
study. As the discharge summary, including the medication
report, was evaluated at discharge in this study, we
expected a further increase in the prevalence of patients
without medication errors from 66 to 90%. With 5%
significance (P=0.05) and power=80%, 46 patients were
needed in both groups.

Data analyses

If not stated otherwise, the results are given as mean
and SD.

Computer software R version 2.5.1 (R Foundation
for Statistical Computing, Vienna, Austria) was used

for all statistical analyses. The R COIN procedure
(asymptotic linear-by-linear association test) was used
to analyse whether there was a significant difference
between the two groups regarding the proportion of
patients without medication errors. The R COIN
procedure implements a unified approach for condition-
al inference procedures. In this study, we used the
asymptotic linear-by-linear association test for ordered
categorical data. The Poisson regression test was used
to compare the number of medication errors per patient
in the groups.

Results

In the intervention group, discharge summaries for a total of
172 patients were evaluated. Of these, 52 patients were also
included in the intervention group in the investigation of
medication errors when transferring from hospital to
community care. The control group for the investigation
of medication errors consisted of 63 patients, for whom the
discharge summaries were not evaluated.

Quality improvement of the information in the discharge
summary

Table 1 shows the result of the evaluation of the
medication report and the medication list and the extent
to which the physician adjusted the discrepancies identi-
fied by the pharmacist. Only 1 out of 172 discharge
summaries was without discrepancies according to the
evaluation checklist. Discrepancies in general information

Table 1 Number and type of discrepancies between the discharge
summary and the medical records and the extent to which they were
adjusted by the physician prior to discharge, distributed over the
different sections in the discharge summary (general information and
layout excluded)

At
evaluation

After
adjustment by
the physician

Adjustments
made

Medication report,
changes made (%)

198 159 39 (20)

Medication report,
reason for the
changes made (%)

259 230 29 (11)

Medication list, current
medications (%)

159 65 94 (59)

Medication list,
indication for current
medications (%)

153 111 42 (27)

1040 Eur J Clin Pharmacol (2009) 65:1037–1046

were seldom put forward to the physician, so a total
scoring was not possible to calculate. When disregarding
this and layout issues, 46 discharge summaries out of 172
were complete and correct.

Regarding the medication report, the pharmacist did
not always inform the physician about the identified
discrepancies, and in these cases the physician was given
no chance to adjust the information. This was seen for
33% of the medication reports with discrepancies. As the
information sometimes was included in the document but
not in the way stated by the checklist, the pharmacists
chose to put forward only discrepancies that risked having
a major negative effect on the patient’s drug treatment. A
tight time schedule did not allow for all discrepancies
to be discussed. The most frequent discrepancy in
the medication list was that medications were missing.
The reason was that the physician had discontinued the
medication without noting this in the medical records.
This was the case for 29% of the medication lists with
discrepancies.

Medication errors when discharged from hospital
to community health care

As presented in Table 2, the patients had similar baseline
characteristics except for whether they were transferred to a
nursing home or their own home. This could indicate that
the patients in the intervention group were more seriously
ill.

The primary research question was whether our inter-
vention decreased the number of medication errors at
discharge from hospital to the community care. The total
number of medications with medication errors decreased
from 12.0% in the control group to 4.8% in the intervention
group, as seen in Table 3. In the intervention group, the
number of medication errors per patient was decreased by
45%, P=0.012. Also the proportion of patients without
medication errors was improved with an absolute increase
of 9.6, from 63.5% in the control group to 73.1% in the
intervention group. However, this increase was not signif-
icant (P=0.319).

Dividing the population into patients with ApoDos and
patients without ApoDos showed that patients with ApoDos
had a 5.9-fold higher risk of suffering from medication
errors than those without this medication dispensing system
(P<0.001).

In the control group, the patients had on average 1.05
medication errors. The errors included commission errors
(0.68 per patient), erroneous changes in dosage (0.24 per
patient), and omission errors (0.13 per patient).
Corresponding values for the intervention group were
0.48, 0.17, 0.17, and 0.14.

Errors in the transfer of information for approximately
one-fifth of the patients were evaluated differently by the
pharmacists. The evaluations were compared and consensus
was reached.

Discussion

Our intervention decreased the number of medication
errors per patient. There was an increase in the
proportion of patients without errors, although this was
not statistically significant. Limitations in the process, as
described below, and also too low a power to detect a
significant difference might be the explanation. We have
previously developed and shown that the medication
report in a discharge summary decreases medication
errors, clinical consequences, and health contacts due to
errors occurring when patients are discharged from
hospital to community health care [18, 19]. This study
shows a further decrease in error rates by improving the
internal hospital discharge process.

In 2000–2001, we performed a descriptive but
otherwise identical study in the same setting to describe
the medication error rates [18]. The proportion of
medications with medication errors after discharge and
return to primary care was 17% and only 46% of the
patients had no error at all. In this study the error rates for
all medications were 12% in the control group and 4.8% in
the intervention group. The proportions of patients

Table 2 Baseline characteristics at discharge for patients included in
the investigation of medication errors when transferring from hospital
to community health care

Intervention
group
(n=52)

Control
group
(n=63)

Age (years) 84 (6.2) 84 (6.7)

Sex: women (%); men (%) 37 (71.2);
15 (28.8)

38 (60.3);
25 (39.7)

Transferred to: nursing home (%);
their own home with help (%)

45 (86.5);
7 (13.5)

48 (76.2);
15 (23.8)

Using medication dispensing system
after discharge (%)

14 (26.9) 23 (36.5)

Medications for continuous use at
discharge, mean (SD)

8.6 (4.2) 7.6 (3.3)

Medications for on-demand use at
discharge, mean (SD)

1.4 (1.5) 1.1 (1.5)

Medications for continuous use in
community health care, mean (SD)

8.3 (4.3) 7.7 (3.2)

Medications for on-demand use in
community health care, mean (SD)

1.3 (1.4) 1.5 (1.6)

Eur J Clin Pharmacol (2009) 65:1037–1046 1041

without medication errors were 63.5 and 73.1% for the
control and intervention groups, respectively. In another
larger study in a similar setting at a university hospital, the
proportions of patients without errors were 34 and 68%
before and after introduction of the medication report in
the discharge summary [19]. There are strong similarities
in the activities, in the error rates, and in the type of errors
between the control group in this study and in
the intervention group from the latter study. However in
the latter study, we did not evaluate the quality of the
discharge summary, and the errors were measured at
discharge based on the discharge summary and not when
patients returned to primary care as was the case in this
study. The latter study also showed a reduction in clinical
consequences based on medication errors [20]. In our
previous descriptive study, there were an average of 2.4
medication errors per patient at admission to the hospital,
and only 15% of the patients had no errors at all [18]. In
this study, a medication interview [15] was performed and
a correct medication list was created and used for each
patient as part of the pharmacist’s responsibilities in the
LIMM model. Also a systematic medication care plan was
set up and used for follow-up and documentation of

activities during the patient hospital stay. This model was
shown to improve medication appropriateness and was
very appreciated by the team [21].

Computerised medical records are a prerequisite for
the hospitals, the primary care, and the community care
to access the same information. In Sweden, 88% of the
hospitals have computerised medical records, in com-
parison with the rest of Europe and the United States
where the numbers are 51 and 12% respectively [17].
With this in mind, Sweden seems to have better
possibilities for providing the health-care system access
to the same information. However, it is important to state
that IT does not solve all problems connected to
communicating and documenting problems in the use
and handling of drugs. It has been stated that electronic
communication between the GP and the community
pharmacists improves agreement but does not suffice as
a solution for obtaining reliable information [23]. Also
GPs found discharge content more important than
delivery method [24].

Medication reconciliation has been introduced as one of
the solutions to decrease medication errors and increase
patient safety [9–11]. The process involves comparing the

Table 3 Medication errors identified by the pharmacist when comparing the medication list in the discharge summary with the medication list in the
community health care, as well as number of medications at discharge and in community health care, in the intervention group and the control group

Intervention group Control group

All
(n=52)

Medication
dispensing system
excluded (n=38)

Medication
dispensing system
only (n=14)

All
(n=63)

Medication
dispensing system
excluded (n=40)

Medication
dispensing system
only (n=23)

Patients without medication
errors (%)

38 (73.1) 35 (92.1) 3 (21.4) 40 (63.5) 32 (80.0) 8 (34.8)

Patients with at least one
medication error (%)

14 (26.9) 3 (7.9) 11 (78.6) 23 (36.5) 8 (20.0) 15 (65.2)

Patients with at least three
medication errors (%)

3 (5.8) 0 3 (21.4) 11 (17.5) 3 (7.5) 8 (34.8)

Patients with at least five
medication errors (%)

1 (1.9) 0 1 (7.1) 5 (7.9) 1 (2.5) 4 (17.4)

Medications for continuous use
at discharge, mean (SD)

8.6 (4.2) 7.9 (4.1) 10.5 (4.1) 7.6 (3.3) 6.7 (2.9) 9.2 (3.3)

Medications for on-demand use
at discharge, mean (SD)

1.4 (1.5) 1.2 (1.4) 1.9 (1.6) 1.1 (1.5) 0.9 (1.4) 1.4 (1.5)

Medications for continuous
use in community health care,
mean (SD)

8.3 (4.3) 7.5 (4.1) 10.4 (4.0) 7.7 (3.2) 6.9 (2.9) 9.2 (3.2)

Medications for on-demand use
in community health care,
mean (SD)

1.3 (1.4) 1.2 (1.4) 1.7 (1.4) 1.5 (1.6) 1.2 (1.5) 2.1 (1.6)

Medications 520 346 174 549 305 244

Medications with medication
errors (%)

25 (4.8) 4 (1.2) 21 (12.1) 66 (12.0) 19 (86.2) 47 (19.3)

1042 Eur J Clin Pharmacol (2009) 65:1037–1046

medications a patient is receiving to what he or she actually
should be receiving and then resolving the discrepancies
[11].

Studies from the UK, Holland, Canada and the U.S.
have been based on development of models for
medication reconciliation at hospital discharge. This
includes telephone follow-up by a pharmacist [12], and
discharge summaries to pharmacies [13, 14, 25–29] and to
the general practitioner [27, 28, 30]. To our knowledge,
our discharge summary is the first systematic tool enabling
information to be produced for the patient and to the next
level of care by the responsible person, the physician. We
have previously shown the benefit of this [18, 19]. Now
we provide evidence for the additional benefit of the
pharmacists’ involvement in the quality assurance of the
medication reconciliation process.

Although the impact of ApoDos on the discharge
process was not the primary research question, we
analysed this since in a previous study we showed that
ApoDos was a risk factor for medication errors [18].
Another reason for analysing the groups separately was
the differences between patients with and without Apo-
Dos, such as number of medications and handling of
medications. As in the previous study in the same setting,
we found the ApoDos system to increase the risk of
medication errors, especially in the control group. The
difference between the two groups is probably that the
clinical pharmacist better identified patients with Apo-
Dos at hospital admission and also highlighted this at
discharge when the regional pharmacy ApoDos dispens-
ing unit is to be contacted. It is interesting to note that
only 3 of 38 patients in the intervention group without
ApoDos had a total of four errors at discharge, and the
error rate for all medications was 1.2%. It is therefore
tempting to conclude that the LIMM model together
with a focus on improving errors in the handling of the
ApoDos system offers the potential to be a very safe
system for medication use in the interface between
primary and hospital care.

Limitations of the study

This is a study based on a new team approach for
improving the patient’s drug therapy. As part of the
approach, we are focusing on reducing medication errors
in the transition of care by improving the medication
reconciliation process. Based on this, we could not
randomise care by patient, or by clusters of physicians,
pharmacists or wards. We could have selected a control
group at another hospital, but based on lack of resources
and also potential differences in baseline (we believed that
our department had few errors), we did not.

We have not included holiday periods during which
staffing can change or be insufficient. However since we
have different time periods to some extent for the groups,
this could have affected the results.

To our knowledge there are no other confounders, such
as organisational changes in the health-care system or
changes in the handling of discharge information in the
hospital or primary care, which can explain the differences
in the results.

Future needs

There is room for improvement in the process of
evaluating the discharge summary, and this could
decrease the errors even further. In general the quality
control and suggestions for change provided by clinical
pharmacists were accepted and corrected especially for
the medication list but also for the medication report.
However, information and education on how to write
the discharge summary, agreement on which discrep-
ancies to prioritise and timing of the interventions
should be improved to improve the process of commu-
nication so that the physician can make more correc-
tions before discharge.

In two studies, we have shown ApoDos to be a risk
factor for medication errors at discharge from hospital to
community care. This process needs to be further investi-
gated to identify the reason for these errors and to study
methods for improvement.

Conclusions

Quality control of the patient’s discharge summary with
correction of errors prior to the patient’s hospital discharge
reduced medication errors in primary and community care.
The quality control and suggestions for change were
accepted and corrected by the physician, if communicated
by the pharmacist.

Acknowledgements First, we would like to thank the students
Helena Lindholm and Cecilia Bergkvist for collecting the majority
of the data. We would also like to thank the staff at the
Department of Internal Medicine at Landskrona Hospital, espe-
cially Dr Per Löfdahl, the nurses in the community health care,
and the clinical pharmacists Sofia Jönsson and Emma Olsson for
excellent cooperation and work.

Funding We are grateful to the National Board of Health and
Welfare, the Swedish Academy of Pharmaceutical Sciences, the
County of Skåne and Apoteket AB for funding the study.

Eur J Clin Pharmacol (2009) 65:1037–1046 1043

Appendix 1

Landskrona Hospital

Department of Medicine, ward 2 Born: 1 Jan 1921
Landskrona Hospital Name: Clara Carlsson

Physician during hospital care: Mats Matsson
General practitioner: Olle Olsson

Hospital care: 1 Jan 2008 – 11 Jan 2008

DISCHARGE SUMMARY

You have been in hospital care because you have experienced dizziness for a period of time and finally you
fainted. When you fainted you fell and now suffer from back pain. Your blood pressure was found to be too low
and this could explain the dizziness. Your medications have therefore been adjusted and your blood pressure is
now back to normal. During your hospital care we also found that you had an infection in the urinary tracts, for
which you now are receiving antibiotics.

After discharge, you will return to the nursing home Flower garden. Within three weeks you will have an
appointment with your General Practitioner, who will measure and follow up on your blood pressure and back
pain.

Medication Report

• Metoprolol has been decreased from 2 to 1 tablets per day, due to low blood pressure.
• Furosemide has been discontinued since you no longer have a problem with swollen ankles.
• Paracetamol has been added because of the back pain from your fall.
• Cefadroxil has been added due to a urinary tract infection.

MEDICINE
preparation and dose

Effect Morning Noon Evening Night Comments

Tabl Metoprolol 25 mg Lowers blood
pressure

Tabl Hydrochlorothiazide 50 mg Lowers blood
pressure

Tabl Metformin 850 mg Against diabetes 1 1
Tabl Paracetamol 500 mg Against back

pain
2 2 2 2 On demand

Tabl Cefadroxil 500 mg Against urinary
tract infection

1 1 Until 13 January

1044 Eur J Clin Pharmacol (2009) 65:1037–1046

Appendix 2

Checklist for quality assessment
Discharge summary with Medication Report according to the Lund model

Prerequisite: Discharge summary carried out according to the Lund model i.e. font size minimum 12 in Times New Roman, headings discharge summary,
planned follow-up, Medication Report (itemised changes) and medication list (including the name of the medication, preparation, dose, effect, comments)
Pharmacist Department/ward Date Patient ID

Summary
Points, if
correct

Number of
observed errors

Total number of points
(=correct – number of errors)

1 Contents 10
2a Medication Report – changes made 5
2b Medication Report – reason for the changes made 5
3a Medication list – current medications 5
3b Medication list – indication for current medications 5

Total score; (maximum 30, minimum 0) =

1. Contents No Comments
A Is the patient’s name and social security number correctly stated? -1
B Is the Discharge summary limited to one page? -1
C Does the Discharge summary contain information on reason for admission? -1
D Does the Discharge summary contain information on the hospital care? -1
E Is the name of the physician during hospital care stated? -1
F Is the name of the general practitioner stated? -1
G Is the hospital care stated as date, month and year? -1
H Does the Discharge summary contain information on planned follow-up? -1
I Do the sentences in the Medication Report begin with the name of the medicine? -1
J Is the full name of the preparation stated (no abbreviations, but tabl, caps, supp is OK)? -1

Number of errors (No)

2 Medication Report Consult medication records etc and state the errors below.
a. Changes made (changes to the medication therapy
during the hospital stay that are not correctly stated)

b. Reason for the changes made (reasons for the changes
in drug therapy are lacking)

3 Medication list. State the discrepancies, based on medications on the day of discharge and the Medication Report, below.
a. Current medications (medicine, dose or comments are
not correctly stated)

b. Indication for the medication therapy is not described
with words understandable for the patient.

Eur J Clin Pharmacol (2009) 65:1037–1046 1045

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