Errors and omissions: Incomplete or incorrect documentation on admission to inpatient rehabilitation.
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| Title: | Errors and omissions: Incomplete or incorrect documentation on admission to inpatient rehabilitation. |
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| Authors: | Rizik JP; Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan, USA.; Division of Rehabilitation Medicine, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA.; Corewell Health Medical Group Spine and Pain Management, Grand Rapids, Michigan, USA., White G; Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan, USA.; Division of Rehabilitation Medicine, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA.; Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, Ohio, USA., Getz M; Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan, USA., Lamm AG; Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan, USA.; Division of Rehabilitation Medicine, Michigan State University College of Human Medicine, Grand Rapids, Michigan, USA. |
| Source: | PM & R : the journal of injury, function, and rehabilitation [PM R] 2025 Aug; Vol. 17 (8), pp. 944-951. Date of Electronic Publication: 2025 May 19. |
| Publication Type: | Journal Article |
| Language: | English |
| Journal Info: | Publisher: Wiley Country of Publication: United States NLM ID: 101491319 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1934-1563 (Electronic) Linking ISSN: 19341482 NLM ISO Abbreviation: PM R Subsets: MEDLINE |
| Imprint Name(s): | Publication: 2019- : [Hoboken, NJ] : Wiley Original Publication: New York, NY : Elsevier |
| MeSH Terms: | Documentation*/standards , Patient Discharge*/standards , Patient Admission* , Rehabilitation Centers* , Medical Errors*/statistics & numerical data , Inpatients*, Humans ; Female ; Male ; Medication Errors/statistics & numerical data |
| Abstract: | Background: As patients move from acute to postacute care settings, clinicians rely on complete and accurate documentation. Errors or omissions during transitions in care expose patients to physical harm, may result in lower institutional quality metrics, expose institutions to medicolegal risk, and may contribute to provider burnout. Objective: To identify the frequency and types of errors encountered in discharge paperwork from acute care hospitals for patients being admitted to an acute inpatient rehabilitation facility. Design: Cohort study. Setting: Tertiary freestanding acute inpatient rehabilitation facility. Patients/participants: The primary admitting provider in two 1-month study periods 1 year apart was sent an electronic survey for each admission completed to identify the presence of a documentation error. Providers were asked to characterize the type of error including the name(s) of medication(s) involved, if applicable. Main Outcome Measures: Presence of an error or omission in discharge paperwork, the type of error, and any medication(s) involved in medication errors. Results: Errors in discharge paperwork were noted in 58 (30.4%) unique admissions out of 191 completed surveys in August 2021 and in 42 (23.2%) unique admissions out of 194 completed surveys in August 2022. Medication errors were most commonly encountered (61.0% and 70.5% of all errors, respectively). Less common errors involved code status, weightbearing status, and bracing instructions, among others. Conclusions: High rates of documentation errors predominantly involving medications were noted during both study periods, which expose patients to the risk of physical harm, jeopardize hospital quality metrics, and expose institutions and providers to medicolegal risk. The presence of such errors requires heightened clinician vigilance to identify and remedy, which may lead to higher levels of provider stress and burnout. Collaboration with acute care hospitals is necessary to further reduce documented rates of errors in discharge paperwork in this systems-level challenge. (© 2025 American Academy of Physical Medicine and Rehabilitation.) |
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| Entry Date(s): | Date Created: 20250519 Date Completed: 20250826 Latest Revision: 20250826 |
| Update Code: | 20250827 |
| DOI: | 10.1002/pmrj.13366 |
| PMID: | 40386880 |
| Database: | MEDLINE |
Nájsť tento článok vo Web of Science | Abstract: | Background: As patients move from acute to postacute care settings, clinicians rely on complete and accurate documentation. Errors or omissions during transitions in care expose patients to physical harm, may result in lower institutional quality metrics, expose institutions to medicolegal risk, and may contribute to provider burnout.<br />Objective: To identify the frequency and types of errors encountered in discharge paperwork from acute care hospitals for patients being admitted to an acute inpatient rehabilitation facility.<br />Design: Cohort study.<br />Setting: Tertiary freestanding acute inpatient rehabilitation facility.<br />Patients/participants: The primary admitting provider in two 1-month study periods 1 year apart was sent an electronic survey for each admission completed to identify the presence of a documentation error. Providers were asked to characterize the type of error including the name(s) of medication(s) involved, if applicable.<br />Main Outcome Measures: Presence of an error or omission in discharge paperwork, the type of error, and any medication(s) involved in medication errors.<br />Results: Errors in discharge paperwork were noted in 58 (30.4%) unique admissions out of 191 completed surveys in August 2021 and in 42 (23.2%) unique admissions out of 194 completed surveys in August 2022. Medication errors were most commonly encountered (61.0% and 70.5% of all errors, respectively). Less common errors involved code status, weightbearing status, and bracing instructions, among others.<br />Conclusions: High rates of documentation errors predominantly involving medications were noted during both study periods, which expose patients to the risk of physical harm, jeopardize hospital quality metrics, and expose institutions and providers to medicolegal risk. The presence of such errors requires heightened clinician vigilance to identify and remedy, which may lead to higher levels of provider stress and burnout. Collaboration with acute care hospitals is necessary to further reduce documented rates of errors in discharge paperwork in this systems-level challenge.<br /> (© 2025 American Academy of Physical Medicine and Rehabilitation.) |
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| ISSN: | 1934-1563 |
| DOI: | 10.1002/pmrj.13366 |