An effective discharge planning process ensures that the patient, patient caregivers, and healthcare providers have the necessary information, support, and resources to facilitate seamless transitions from one level of care to another. A comprehensive discharge planning process can improve patient outcomes by reducing the likelihood that lengths of stay are inappropriately prolonged or shortened and by reducing readmission rates or repeated services.
In addition to improving patient outcomes, a discharge planning process provides a risk management strategy for reducing the organization’s liability risk. Shortcomings in discharge planning can lead to patient injury or death, and subsequent litigation can result in substantial jury awards. For example, in 2024, one patient was awarded $45 million after a jury found the treating hospital failed to provide proper post-discharge care instructions.
Unfortunately, the discharge planning process is often fragmented, highly variable, and in some cases, haphazard and rushed.
Because effective discharge planning remains a patient-safety challenge for many healthcare organizations, identifying barriers to safe, effective discharge is the first step to informing strategies for improvement. One such barrier is inadequate communication and coordination during discharge, which ECRI identified as one of the Top 10 Patient Safety Concerns for 2025.
Communication Breakdowns Among Healthcare Professionals During Discharge
The ability to effectively collaborate and transmit information among healthcare providers is central to the provision of safe, high-quality medical care. However, the increasingly complex healthcare environment can complicate the communication process and hinder the information exchanges necessary for optimal care. Communication breakdowns can be disastrous during the vulnerable discharge period, resulting in, at best, confusion for the patient and their caregivers and, at worse, patient injury, readmission, or even death.
To address broader communication breakdowns, healthcare leaders can develop a strategic initiative to improve transitional care services, such as by using structured communication tools like SBAR (Situation, Background, Assessment, Recommendation) or I-PASS (I stands for illness severity; P stands for patient summary; A stands for action items; S for situational awareness; and S for synthesis by receiver). Leaders can also include planned discharges in daily safety huddles so staffing and transport resources can be allocated appropriately.
One communication tool that healthcare professionals rely on is a discharge summary, which conveys critical information about the patient's current condition, test results, post care instructions, medication list, and treatment plan to other clinicians who may care for the patient. However, discharge summaries that lack essential details or use unclear language, such as abbreviations, can lead to confusion, delays in treatment, and increased readmission rates.
Implementing a process to ensure that discharge summaries are clear, accurate, and standardized enhances patient safety during care transitions. This is particularly effective when summaries are promptly shared with admitting healthcare facilities, primary care providers, and patients.
According to one study, there are 29 items that should always be included in elderly patient discharge summaries; as a best practice, these items can also be used for patients of any age. These items include discharge medications, procedures performed in the hospital, laboratory tests and investigation results, the patient’s physical and cognitive functional ability at discharge, reasons for changes in medication during the patient’s hospital stay, adverse reactions during stay, discharge instructions, and the discharging physician’s contact information. Additional best practices include requiring the discharging physician to ensure medication information is complete, avoiding the use of all capital letters, emphasizing important information, including page numbers in the format “xx of yy pages,” displaying all section headings, and requiring the discharging physician to indicate sections that are intentionally left blank.
Electronic health records (EHRs) enable information sharing and care coordination among providers and multiple healthcare organizations. However, incomplete or inaccurate data entries can lead to errors in care. To address these risks, it is essential to implement processes for regular EHR updates and ensure follow-up on critical information, such as test results.
In addition, patients may see providers in different healthcare systems, with each using a different EHR platform. When these systems fail to "talk" to each other, providers may be left without critical health information. This lack of real-time, accurate data exchange undermines the purpose of EHRs, underscoring the need for direct communication between healthcare professionals.
Communication Breakdowns During Medication Reconciliation
Medication errors can also arise if discharge summaries do not include accurate medication information. In a systematic review of studies on medication errors, the median rate of unintentional medication discrepancy was nearly 50% in adult and elderly patients post discharge. Errors may include omissions, duplications, incorrect dosages, or unintentional changes in medications.
The process of medication reconciliation is intended to detect and prevent medication errors by systematically evaluating the medications a patient is taking to ensure that any additions, changes, or discontinuations are carefully reviewed, with the goal of maintaining an accurate list. The process should be undertaken at every change in a patient's level of care, including discharge.
To address communication breakdowns during medication reconciliation, healthcare leaders should develop a standardized approach to completing the steps of reconciliation each time a patient transfers to a new level of care. These steps should include verification of the patient’s medication history at every transition or discharge, clarification of medications and doses, and reconciliation, or documentation, of changes. Leaders may develop and support the use of checklists or other standardized forms to ensure consistency in collecting and verifying medication histories, and should designate who is responsible for each role in the process. Patients and pharmacists should also be involved in the process.
Communication Breakdowns Between Providers and Patients: Unclear Discharge Instructions
Effective communication and coordination between healthcare professionals and patients, their families, and caregivers are also crucial for ensuring a safe patient discharge. Engaging patients and families in the discharge planning process has been shown to result in reduced hospital readmissions. One strategy for engaging patients during discharge is the IDEAL process (I stands for include patients and families as partners; D stands for discuss key home care areas; E for educate in plain language; A assess understanding using teach-back; and L for listen to and honor preferences and concerns), developed by the Agency for Healthcare Research and Quality.
Barriers that contribute to ineffective communication during discharge include low patient health literacy, anxiety, fatigue, cognitive impairment, and language barriers. Time pressure can also be a contributor, since clinicians are often juggling multiple discharges, leading to rushed or fragmented conversations. Discharge instructions may be written at a reading level that is too high or may not be culturally or linguistically appropriate. Inconsistencies between verbal instructions and discharge paperwork can cause further misunderstanding.
To address these challenges, healthcare professionals can adopt several evidence-based strategies. Using the teach-back method—asking patients to repeat key instructions in their own words—is one of the most effective ways to ensure patient understanding. Discharge materials should be written in plain language and translated into the patient’s preferred language when necessary. Clinicians should also begin discharge planning early during hospitalization, allowing time for repeated education and clarification.
It is critical to ensure that the patient and their caregivers are positioned as partners in care throughout hospitalizations and medical encounters. By encouraging continuous patient and caregiver involvement, healthcare teams can avoid disconnects that frequently occur during discharge communication. Finally, directly involving family members or caregivers in the discharge process can provide additional support and help reinforce instructions once the patient returns home.
A fragmented discharge process goes beyond being a patient-safety workflow issue; it signifies a systemic failure. Healthcare organizations should examine the discharge workflow to identify challenges to safe, effective discharge. By understanding and redesigning the discharge process, organizations can reduce preventable patient harm.