Providing Patients with ISMP Consumer Leaflets Can Help Prevent Hospital Readmissions

Guest post by Ann Shastay, MSN, RN, AOCN, Managing Editor, Institute for Safe Medication Practices (ISMP)

Amy Shastay_6.24.16The stakes have never been higher for hospitals to prevent patient readmissions within 30 days. While the ability to predict which patients are at high risk for readmission is not an exact science, numerous studies have identified that adverse medication events are at the very core of the readmission problem.1-3 This includes patient non-adherence to prescribed drug therapy, which by itself leads to treatment failures and wasted resources costing $150 billion annually.4 A study by Budnitz et al. identified the drugs involved in 88.3% of emergency hospital readmissions of older adults caused by adverse drug events: hematologic, endocrine, cardiovascular, central nervous system, and anti-infective agents.3 Nearly two-thirds of the hospitalizations were due to unintentional drug overdoses. Just four types of medications—warfarin, insulins, oral antiplatelet agents, and oral hypoglycemic agents—together accounted for 7 in 10 of the emergency hospitalizations. A review of 55 observational studies found that information related to medications was missing from hospital discharge summaries up to 40% of the time.5 Another study found that patients with medication discrepancies had a 30-day hospital readmission rate of 14.3% compared with 6.1% for patients without a medication discrepancy.6

 Because patient education has been shown to improve health outcomes and reduce the risk of preventable adverse drug events,7 nurses and pharmacists can play a central role in reducing hospital readmissions by teaching patients and their families about the medications that have been prescribed upon discharge. Particular attention should be paid to teaching patients about the risks associated with taking any medications identified in the Budnitz et al. study and those on ISMP’s list of high-alert medications dispensed in the outpatient setting.

resources - reportsTo assist with patient education, ISMP has developed and tested more than a dozen consumer leaflets that offer important safety tips for taking high-alert medications. Included are leaflets for warfarin, enoxaparin, fentaNYL patches, oxyCODONE with acetaminophen, HYDROcodone with acetaminophen, oral methotrexate, and various insulins. These leaflets are readily available on the ISMP website at no charge to use in your organization to educate patients. (We have recently made them available in Spanish as well.) The “Top 10 List of Safety Tips” on the front of each leaflet is intended to help patients detect and prevent medication errors and other adverse drug events. The safety tips were derived from reports of actual adverse events with these medications submitted to various national and state reporting programs. For example, one safety tip in the warfarin leaflet advises patients who have been told to stop taking warfarin until their next lab test to call their doctor if they don’t hear anything within 24 hours of the test to find out the next steps. This tip is included because there have been numerous reports involving patients who developed a thrombus because they never resumed taking warfarin after it was on hold until the next International Normalised Ratio (INR).

Through a grant from the Agency for Healthcare Research and Quality (AHRQ), ISMP tested the readability, usability, and perceived value of the leaflets. Ninety-four percent of patients felt the leaflets provided great information or good information to know after receiving it when picking up a prescription at their community pharmacy. Ninety-seven percent felt the information in the leaflets was provided in a way they could understand. Eighty-two percent of patients taking the drug for the first time learned something new after reading the leaflet, and almost half (48%) of the patients who had previously taken the medication reported learning something new. Overall, 85% of the patients felt they were less likely to make a mistake with the medication because they had read the leaflet. Pharmacists who handed out the leaflets also reported that they were highly useful in guiding the educational sessions with patients. Given the very favorable response to the leaflets during the study, ISMP hopes that any healthcare professional caring for patients taking one of these high-alert medications will download the leaflets from our website, use them as a resource when educating patients about the medications, and provide them to patients to read and refer back to as needed.

Oral MedsISMP believes that professionals should focus patient education on those issues that cause the most harm and are likely to result in a readmission. No patient discharged with a prescription for a fentaNYL patch should be sent home without being specifically informed to remove the old patch before applying a new one. No patient being discharged on methotrexate for arthritis or psoriasis should be sent home without warnings regarding the risks associated with taking the medication daily instead of weekly. No patient who takes a combination opioid analgesic upon discharge should go home not knowing the daily acetaminophen limit and to avoid taking other common over-the-counter products that contain acetaminophen while taking this product. No patient with a prescription for enoxaparin should be sent home without knowing how to dispose of the used syringes safely. No patient discharged with a prescription for an insulin pen should arrive home without knowing that it should never be shaken prior to use. Given that discharged patients may remember little of what has been discussed in the hospital, the leaflets are a great way to ensure that patients are armed with information they need to avoid a medication mishap once they go home.


  1. Forster AJ, Murff HJ, Peterson JF, et al. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2006;20(4):317-23.
  2. Davies EC, Green CF, Mottram DR, et al. Emergency re-admissions to hospital due to adverse drug reactions within 1 year of the index admission. Br J Clin Pharmacol. 2010;70(5):749-55.
  3. Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:2002-12.
  4. Erickson J. The cost of medication noncompliance. J Am Assoc Preferred Provider Organ. 1993;(2):33-4,38-40.
  5. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. 2007;297(8):831-41.
  6. Coleman EA, Smith JD, Raha D, et al. Post-hospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165:1842-47.
  7. Guirguis LM, Chewning BA. Role theory: literature review and implications for patient-pharmacist interactions. Res Social Adm Pharmacy. 2005;1:483-507.


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