Medication discrepancies upon hospital to skilled nursing facility transitions.
Approach to Improving Safety
- Discontinuities, Gaps, and Hand-Off Problems
- Medication Errors/Preventable Adverse Drug Events
- Specific to High-Risk Drugs
Setting of Care
Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to medication errors, as they are often elderly, have multiple chronic illnesses, and take multiple medications. In this study, medication discrepancies (among the hospital discharge summary, SNF referral form, and SNF admission orders) were the rule rather than the exception. Most concerning, many discrepancies involved high-risk medications such as opioid analgesics, anticoagulants, and hypoglycemic agents, which have been linked to serious medication errors in elderly patients. While The Joint Commission has mandated medication reconciliation for long-term care facilities as part of the 2009 National Patient Safety Goals, the authors note that many SNFs do not maintain Joint Commission accreditation, implying that state or national regulations may be needed to improve medication safety across the hospital–SNF transition.