Hospital admissions are a vulnerable time for patients and their families. Several factors have an impact on these situations—there may be an acute change in an individual’s clinical condition, new physicians and clinical teams become involved in the medical decision making, and there may be gaps in the information available. All of these elements can increase a patient's risk of complications or poor outcomes. Taking a little time to minimize risk can go a long way in increasing patient safety.
- Perform a medication reconciliation on admission
Medication reconciliation is a growing area of focus of regulatory agencies. The Joint Commission added medication reconciliation to the National Patient Safety Goals for 2024, and the World Health Organization has written a standard operating protocol regarding medication management during clinical care transitions. Errors and adverse drug events are in part related to inaccurate knowledge of a patient’s medication list at the time of admission. Medications could be initiated on admission that had been discontinued or adjusted while an outpatient. New medications could be omitted. The responsibility for reviewing and confirming active outpatient medications at the time of admission can be performed by many individuals—pharmacists, pharmacy technicians, advanced practice providers, and physicians. Ultimately, the admitting provider is responsible for acknowledging that the list is accurate and making the decision as to which medications should be continued or held at the time of admission. - Perform a medication reconciliation at discharge
Just as important as getting the medications accurate upon admission is to ensure that medications are clear at the time of discharge. It should be clear to the patient and their social support group which medications are new, which ones have had doses adjusted, and which medications need to be discontinued. This information is also important for the clinical care team that will be taking over the patient’s care after discharge. - Notify the outpatient care team of admission and discharge
The Agency for Healthcare Research and Quality has recently promoted the importance of communication between the inpatient and outpatient care teams to minimize the risk of errors. While not all patients have an outpatient clinician actively involved in their care, many do. It is important for there to be communication of some kind (written or verbal) between the healthcare teams. Patients may not be able to convey the entirety or complexity of a hospitalization, especially in a standard outpatient clinic visit encounter where time is a valuable commodity. - Discuss and document resuscitation wishes
While unexpected acute cardiopulmonary resuscitation is a rare event even in hospitalizations, there is a reason why patients are in the hospital. They are acutely ill and sudden events cannot always be predicted. It is important to have the conversation with every patient during every admission regarding their wishes in the event of circulatory or respiratory collapse. This isn’t a discussion to have with patients or their family members in an emergent setting. Documenting the patient’s wishes is important, but as a bonus, having that conversation with caregivers present can also be beneficial. - Sit down when you are in the room seeing patients
It’s such a minor action on the provider side, and yet it has a powerful impact on patients. A randomized controlled trial with patients undergoing spine surgery showed that the perception of time spent between patient and provider was higher when the provider sat down, even though the actual time spent was the same. There has also been correlation of sitting for the encounter with improved patient compliance and patient satisfaction. - If there are concerns about a clinical change, it’s good to get eyes on the patient
Calls from the nursing team range from minor to critical. And sometimes there are the in-between calls where it isn’t entirely clear how concerning the patient’s symptoms or findings are. When in doubt, going to see the patient or having another clinician go to see the patient can be very beneficial. In addition to obtaining a brief history and physical, being present can provide reassurance for the patient and for the nursing team. This allows for more opportunities to communicate with all of the involved parties. - Review your differential diagnosis on admission (and throughout admission if needed)
Anchoring bias is when one’s attention and decision making is based on the initial information presented. This can lead to missed diagnosis and delayed treatment due to failure to consider other potential diagnoses. One way to avoid this is to intentionally and consciously review the differential diagnosis, particularly at the time of admission or initial consultation. - Pick up the phone and talk with consultants
George Bernard Shaw said, “The single biggest problem in communication is the illusion that it has taken place.” Communication is often cited as a failure in malpractice cases, and inpatient care is no exception. Some providers document more clearly than others, and some have different perspectives as to what information is relevant to include. When in doubt about a diagnosis or a plan for a mutual patient, reach out to their other provider(s) and discuss the care. - Document the plan for the day clearly, and early if possible
Documentation in the health record serves many purposes. One purpose is to facilitate communication within the care teams. Early and clear documentation of the plan for the day helps to get the entire team on the same page for the patient’s care. This can decrease the need for pages, chart messages, and phone calls that interrupt a busy clinician throughout the day. - Leverage the power of electronic health record (EHR) systems to gather information
Errors in clinical care can occur when not all relevant information is reviewed or available. Electronic health records can be both a blessing and a curse when it comes to information. Note bloat and outdated information can make it difficult to find relevant information. More and more, information from outside systems are accessible through the inpatient EHR. Focusing on specific high-value, high-risk information can be helpful, such as allergies and medications.
Information in this article is for general educational purposes and is not intended to establish practice guidelines or provide legal advice.
Article originally published in 1Q25 Copiscope.