Starts at admission.1

A multidisciplinary consensus panel of experts (in acute, chronic, home, and long-term care and in rehabilitation medicine) convened by the Ontario Ministry of Health and Long-Term Care developed a safe hospital-discharge checklist of evidence-based predischarge, postdischarge, and bridging practices, categorized into the following seven domains that represent events that should be completed during a typical hospitalization:

1. Indication for hospitalization

2. Primary care

  • Identify/confirm primary care physician (PCP)

  • Contact/notify PCP of patient admission, diagnosis, predicted discharge date

  • Schedule PCP follow-up within 7–14 days of discharge

3. Medication safety

  • Reconcile home and admission medications

  • Teach proper use of discharge medications and their relation to prior home medications

  • Reconcile discharge, prior-home, and hospital medications2



    A discharge timeout process prevented prescribing errors.

    During hospitalization and subsequent discharge, medications often are modified or changed, which can be a source of confusion for patients and providers and can result in medication errors. Investigators at an 885-bed academic teaching facility examined the rate of prescribing errors during 60 days before and after instituting a discharge timeout process whereby all members of the medical team met to review the patient record and complete a standardized discharge form.

    The timeout was completed in 2 to 3 minutes; it included a review by a clinical pharmacist who compared the patient's home medical regimen with the inpatient list of medications. The pharmacist and medical team then came to a consensus on discharge drug regimen and length of treatment. Pharmacists and case managers discussed financial and psychosocial barriers to drug availability. Prescribing errors were detected in 35% of 142 discharges before the intervention and in 13% of 124 discharges after the intervention. Adherence to the timeout process was 93%.


    A team-based interaction eventually could join the arsenal of safety practices.


4. Follow-up plans

  • Postdischarge follow-up phone call within 72 hours for high-risk patients (high LACE index score [Length of stay, Acuity on admission, Comorbidity, and Emergency department visits])

  • Arrange outpatient studies (e.g., lab, radiology) if needed

  • Arrange specialty clinic follow-up if needed

5. Home-care referral

  • Home-care agency shares information about patient's preexisting community services

  • Engage home-care agencies

  • Schedule postdischarge home care (if needed)

6. Communication with outpatient providers — provide discharge summary, medication reconciliation information, and inpatient attending contact information to patient, PCP, community pharmacy, and caregiver

7. Patient education

  • Use teach-back method

  • Explain relation between new medications and diagnosis

  • Explain discharge summary

  • Explain expected home course, including anticipated or possible symptoms and circumstances and when patient should contact his or her physician

The checklist is intended to be used during daily interdisciplinary hospital rounds. Checklist review and time-delimited interventions are encouraged to assure early patient education, communication with PCPs, medication reconciliation, and use of validated tools to identify patients who are at high risk for readmission.


The hospital discharge transition process is complex, and care coordination with a multifaceted discharge checklist makes sense. Who should complete each task on the list is not identified nor has this checklist been evaluated in clinical practice. Nevertheless, healthcare organizations and physician groups should find the checklist a valuable systematic way to manage a healthcare system's discharge processes actively.

Dr. Finn is a hospitalist and the Inpatient Associate Program Director for the Internal Medicine Residency Program at Massachusetts General Hospital in Boston.


1. Soong C et al. Development of a checklist of safe discharge practices for hospital patients. J Hosp Med 2013 Aug; 8:444. (

2. Beardsley JR et al., Hosp Pharm 2013 Jan 48:39