Danger Ahead—You Are Being Discharged

Transitions of care are potentially dangerous times for patients as they travel through the health care system.Nowhere is this more evident than on discharge from hospital.Over an 11-month period about a decade ago, the Canadian Institute for Health Information found that hospital readmission within 30 days of initial discharge was common (estimated at 8.5%), costly (at $1.8 billion), and preventable more than half of the time. 1 Medication-related issues have been identified as an important contributor to readmissions, with prescribing problems and adherence issues most frequently cited. 2 Three papers in this issue highlight the discharge process, each emphasizing an important message.First, discharge planning needs to start early during hospital admission and should include a comprehensive medication review to prevent inappropriate prescribing on discharge, which in turn has the potential to reduce drug-related readmissions.Second, patient perspectives should be considered in discharge planning, something that is all too often neglected in our overwhelmed health care system these days.Finally, pharmacists need to critically think about how and when we perform evidence-based discharge activities.The need for comprehensive medication review as a component of early discharge planning is demonstrated by Madey and others. 3These authors identified prescribing issues that can arise for older, frail persons who receive antipsychotic agents during hospitalization.For one-third of the patients, these drugs were continued at discharge, with only 15% having a documented postdischarge antipsychotic follow-up plan and 40% still having an antipsychotic prescription at 180 days after discharge, putting them at risk of well-documented medication-related harms.While there are valid indications for antipsychotic use in older persons, these agents are not generally required over the long term when used for delirium, a common reason for prescribing antipsychotics during hospitalization.Moreover, when used for behaviours related to dementia, a plan for reassessment at 3 months should be in place. 4adey and others 3 identify comprehensive medication review as one means to ensure that antipsychotics prescribed in hospital are not continued inappropriately on discharge.This approach is consistent with guidance from the World Health Organization, which has identified

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