Table 2.

Example quotes from the interview transcripts illustrating hazards for adverse drug events following hospital discharge

Home work system - medication task related	“Amiodarone and other medications that have loading doses. Not understanding the loading dose when it’s finished and when to switch to the maintenance dose.” [Transitional care nurse practitioner. Hazard coded: Complex dosing]
Home work system - patient and caregiver related	“I had one just yesterday who decided she was going to stop taking her Janumet twice a day, and only take it once a day. The nurse practitioner had already urged her to take it as directed, but “No, I need to cut back on my medicines.” [Case manager. Hazard coded: Unsafe practices at home]
Home work system – resource related	“Even though you don’t need blood work with it and it is supposed to be much better, they can’t afford it.” [Pharmacy technician. Hazard coded: Unaffordable cost]
Hospital work system	“Sometimes, we see that the discharge summary is wrong and the patient says ‘Well, they gave me a prescription for this,’ but it’s not listed on the sheet that the patient takes home, which is really concerning.” [Case manager. Hazard coded: Errors in discharge medications]
Collaborative work	“[T]hey could have been sent home, for instance, they were at home taking Lasix 20 mg and now they have a prescription coming home that they filled for furosemide 40 mg. They don’t see that it is the same med, right?” [Care coordination nurse. Hazard coded: Inadequate handoffs for patients and caregivers to manage changes]
External environment	“They said Toprol for 30 days, am I supposed to stop it? … You are going to be like “Here is 30 days. You need to see somebody because you need to make sure blood pressure is tolerating it.” [Hospitalist. Hazard coded: Gaps in access to care or in sharing medication information]