Improve communication, accuracy, and patient safety by reviewing the discharge workflow.  See the attached slides that were presented at the Housestaff Meeting November 17, 2016.

The Setting

Hospital discharges

The Players

• The provider
• The nurse
• The patient
• The discharge instructions

The Situation

Patients, nurses, and providers want an accurate medication list when patients are discharged from the hospital.  However, we are often finding the medication lists on the the Patient Discharge Instructions are inaccurate.  Here are a few situations:

• The provider hasn’t completed the Med Rec when the Discharge Instructions are printed.  Which medication is the patient supposed to take?
• Medications appear duplicated on the Med Rec.  Which one is the patient supposed to take?
• Prescribed medications don’t get listed as being electronically prescribed.  Did the provider ePrescribe the medication?

The Proper Discharge Workflow

1. Problem List
2. Patient Education
3. Follow-up Instructions
4. Medications
   1. Resident Proposes Medications
   2. Attending Co-signs Medications
   3. Medication Reconciliation*
5. Discharge Orders**
6. Discharge Summary

*Key Point: The Medication Reconciliation should occur after any proposed medications are co-signed by a licensed provider.  Un-signed proposed prescriptions do not appear on the Med Rec, and medication duplication often happens when the unlicensed provider performs the Med Rec prior to co-signing proposed prescriptions.

**Key Point: The Discharge Orders should occur after the Medication Reconciliation is completed. As soon as the Discharge Orders are initiated, the nurse may print the Discharge Instructions, which means all the discharge information should be completed at that point, including the co-signing of any proposed medications and the Med Rec.