Failure In Discharge Planning

May 27, 2015    |   By: Calevir

The Huffington Post and McKnight’s recently highlighted the story of a North Carolina resident who called 911 because he had been discharged from the hospital to rehab and then to home, but could not get food—or much of the other care he needed.  Elizabeth Leis Newman of McKnight’s pointed out how this gentleman’s crisis reflects the giant gaps in discharge planning in much of the US.  Fortunately, providers are beginning to realize how seriously we fail our patients when we release them without the capacity or resources to be well.  But this story highlights how this isn’t just a hospital or SNF problem, including the potential for involving EMS providers as eyes, ears and hands.  Each provider along the way can and should contribute to the solution.  Unfortunately, the discussion of quality and safety issues in such groups of providers often falls outside the protections of state quality assurance legal protections.  But if they all participate with a Patient Safety Organization, much of that work can take place in a protected space and other providers can learn from their work.

Did you know that by 2017 the ACA will require all hospitals that want to participate on the insurance exchanges to participate with a PSO and to meet quality measures to prevent readmission?  Providers can take advantage of the PSO’s two distinct benefits:  sharing the learning and protecting the work.  For more information about PSO participation for hospitals, LTC or EMS, contact the Center for Patient Safety.


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

Read More


The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.