SHM Converge Scientific Abstract ePoster Gallery-Examining the Frequency and Outcomes of Inaccurate Discharge Summary Medications

Pdf Summary

This project examined how often discharge summary medication lists were inaccurate and whether that affected patient outcomes. Researchers reviewed discharge summaries for all patients leaving a general internal medicine service between December 1, 2021 and December 2, 2022 (7,892 patients). They found that 761 patients, or 8.9%, had an unreconciled medication list at discharge.<br /><br />The study’s goals were to measure baseline rates of medication reconciliation errors and 30-day readmissions, map the current discharge process, and use an Ishikawa (fishbone) diagram to identify barriers to accurate discharge documentation. The team also reviewed 7-day and 30-day hospital readmissions, clinic visits, and emergency department visits.<br /><br />The analysis found no difference in the primary outcome of 30-day readmissions overall. However, secondary analysis showed a significant association between unreconciled discharge medication lists and 7- and 30-day hospital readmissions among patients discharged to skilled nursing facilities.<br /><br />A key workflow issue identified was the auto-populated medication list in the discharge summary template. This text can become inaccurate unless it is generated or manually refreshed after final medication reconciliation. The authors note that many discharge steps are standardized or automated, but several still depend on human factors.<br /><br />As a next step, the team plans to implement an electronic medical record intervention that prompts physicians to review and refresh the auto-populated discharge summary text when signing it. A post-intervention study will assess whether this improves medication reconciliation and patient outcomes.

Asset Subtitle

Sarah Linson

Meta Tag

Author List Heather Balch, Sarah Linson, Stacy A. Johnson

Category Research

Concept Medication Reconciliation

Concept Discharge Summary

Concept Medication List

Concept Medication Documentation Error

Concept Quality Improvement Intervention

Distinguished Non-Finalist

Presenter Organization University of Utah Health

Presenting Author Sarah Linson

Track Transitions of Care

Keywords

discharge summary

medication reconciliation

unreconciled medication list

patient outcomes

30-day readmission

hospital readmission

general internal medicine

skilled nursing facilities

electronic medical record intervention

auto-populated discharge template

Medication Reconciliation

Discharge Summary

Medication List

Medication Documentation Error

Quality Improvement Intervention