TABLE 2.

Examples of Identified Postdischarge Transition-of-Care Events (TCEs)

	No. of TCEs (%) N = 139	Representative examples
Discharge communication/coordination	58 (41.7)	Discharge summary or other crucial paperwork did not arrive with patient at post–acute care facility.
		Postdischarge follow-up appointments were missing or not scheduled in a timely fashion.
		Patients were discharged to post–acute care site without appropriate postoperative devices or documentation of recommended duration of use (eg, sling, cervical collar).
		Past medical history was inappropriately or inadequately documented.
		Postoperative anticoagulation plans were inadequately communicated to the post–acute care team.
		Certain medications required at the time of patient arrival at SNF were difficult to arrange (eg, posttransplant immunosuppression medications not routinely available at SNF).
		There were discrepancies noted in patients’ documented code status.
		Inadequate documentation was provided about the desired/expected course for new medications (eg, steroids, antibiotics).
		Mental status and delirium were poorly documented.
Medication	53 (37.4)	Medication reconciliation was incorrect or had notable omissions, discrepancies, duplicates, or dosing errors.
		Adjustments to medications based on changing renal function (reduction in NSAIDs, dosing of antibiotics) were recommended.
		Lifelong antibiotic therapy was inadvertently omitted from discharge medication list and was not continued at SNF.
		Duplicate medications, or medications from the same class (eg, beta blockers) were listed.
		Anticoagulation concerns were noted (eg, discharged on incorrect dosage of enoxaparin; documentation of DVT treatment not included for patient arriving with coumadin and subtherapeutic INR).
		Posttransplant immunosuppression regimen was left off of discharge medication list.
Medical	27 (19.4)	Pain medications were discontinued at hospital discharge, resulting in a patient arriving in severe pain.
		Patient arrived at SNF with hypoglycemia.
		Patient arrived to SNF with apparent hypoxia and new oxygen requirement.
		Patient with recent DVT was noted to have persistent subtherapeutic INR.
		Patient did not have appropriate lab monitoring, including preoperative or postoperative bloodwork, prior to SNF arrival.
		Patient was noted to have new anemia; SNF had limited capacity to evaluate and treat.
Other	2 (1.4)	Patient had health insurance issue that was not addressed, and did not receive inpatient social work assessment.
		Patient did not receive adequate care at home.

Abbreviations: DVT, deep vein thrombosis; INR, international normalized ratio; NSAID, nonsteroidal anti-inflammatory drug; SNF, skilled nursing facility; TCE, transition-of-care event.