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The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2022;31:278-286.
Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for seniors and other high-risk patients. The social worker/nurse practitioner team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers.

Under a program known as the Care Transitions Intervention ®, a Transitions Coach ® encourages patients who are transferring from either a hospital or a short-term skilled nursing facility stay to home to assert a more active role in their self-care. The program has consistently reduced 30-day hospital readmissions and costs as well as 180-day hospital readmissions, even in heavily penetrated Medicare Advantage markets in which the reduction of hospital use has been an explicit focus for many years.

Backman C, Cho-Young D. Patient Prefer Adherence. 2019;13:617-626.
Hospital discharge is a complex process that requires patient and caregiver engagement in order to transpire safely. Interviews with members of a Canadian patient safety organization who had recently been discharged from the hospital revealed that they desired better communication as well as more attention to their social determinants of health. A PSNet perspective discussed interventions to improve safety during the transition from hospital to home.
Society of Hospital Medicine
This Web site provides resources associated with the Better Outcomes for Older adults through Safe Transitions project, called Project Boost. This national initiative designed tactics to improve the safety and quality of patient transitions from hospital to home. The program provided hospitals with implementation assistance to use tools in general and specifically for their environments, such as pediatrics.
Sentinel Event Alert. 2006;35:1-4.
This alert emphasizes the importance of reconciling medications and supports implementation of this Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) National Patient Safety Goal. Note: This alert has been retired effective August 2016. Please refer to the information link below for further details.