CPS Safety Watch/Alert: Home Health Medication Management

May 18, 2016    |   By:

PSOalertA Home Health Care News article came out on 5/3/16 noting that medication mismanagement is an area in which home health agencies are woefully lacking. This article cited a Kaiser Health News Analysis of government records showed that inspectors identified 3,016 home health agencies (nearly a quarter of all agencies examined by Medicare) that inadequately reviewed or tracked medications for new patients. Medication mismanagement is seen as a major post-discharge complication as federal data shows that fewer than 50% of discharged patients are confident that they understand and can follow their discharge instructions.

Contributing factors to these medication errors include, lack of organization, lack of patient education and a lack of communication. Another factor which plays into the lack of communication is the fact that the government incentive to shift to electronic medical record was not set up to work across the continuum of care.  In effect, it contributes to setting up silos within the healthcare continuum as hospitals are not connected with home health care agencies outside of their own system and maybe not even within their own system depending on the software utilized by the hospital and the home health agency.

A review of data submitted to the Center for Patient Safety shows a similar trend in medication events.  Over a third of the medication events reported in the home health arena can be attributed to errors during med reconciliation and lack of communication during the transition from hospital to home health.

Suggested practices to reduce these errors include:

  1. Standardizing communication when a patient is being discharged from the hospital to home health. Include:
    1. Medication changes
    2. Completed and pending tests
    3. Follow up appointments
    4. DME needed by the patient
    5. Education provided to the patient
  2. Double-check medication
    1. Ensure important chronic medications were not stopped
    2. Make certain new medications are safe
    3. Double-check the interactions between medications
    4. Make certain patient hasn’t been prescribed two duplicate medications
  3. Transition the patient to home during the week
    1. Ensures that the patients primary care physician is available for medication questions
    2. Ensures that DME agencies are available to provide the patient with any equipment needed
  4. Patient Education
    1. Make certain the patient (and the family/primary caregiver) understand the diagnosis and medication prescribed
    2. Ensure they understand who they are to contact with any questions
    3. Is the patient/family aware of follow up appointments?
    4. Are they aware of lifestyle changes that may be required?
    5. If so have they been provided with information for support groups?

Patient safety is a major health issue which adversely affects patients in every health care setting.  Improving patient safety is a complex issue, which requires a total systems approach.  Implementing a patient safety culture in which leaders and front line staff put patient safety as a priority across the continuum of care is the foundation for preventing harm.  Reviewing processes and completing RCA’s of all events provides learning opportunities and also identifies areas of improvement.  But for the total systems process to work, an organization must have in place that strong patient safety culture where employees feel free to identify errors and unsafe conditions.











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.