Unplanned Medication‐Related Hospital Readmission following Transfer to a Residential Care Facility

Abstract

ABSTRACTBackgroundAnecdotal evidence suggests that current medication arrangements following discharge from hospital to residential care facilities sometimes lead to medication delays and errors, which may result in adverse outcomes.AimTo describe a case where delays in initiating a revised antiepileptic medication regimen may have contributed to adverse clinical outcomes for a patient requiring unplanned hospital readmission.Clinical detailsA 41‐year‐old man was admitted to hospital from a residential care facility with seizures and hyponatraemia. Multiple changes were made to the patient's antiepileptic medication regimen and he was discharged on Day 11 (a Sunday). Following discussion with the residential care facility and their designated community pharmacy, it was agreed that the community pharmacy would dispense his medications and pack them into a dose administration aid, and the residential care facility would organise for a new medication chart to be written by a general practitioner. The hospital doctor prepared a discharge summary and a copy of the discharge prescription was faxed to the community pharmacy. The patient was discharged from hospital with no medications. 3 days later he was readmitted to hospital with seizures, falls and a subdural haemorrhage. On review, the revised antiepileptic regimen had not been implemented at the residential care facility. The patient spent a further 11 days in hospital before returning to the residential care facility.ConclusionTransferring patients from hospital to residential care poses challenges to continuity of care. Improved discharge planning processes to ensure continuity of medication administration on discharge to a residential care facility are urgently needed.