Errors and omissions: Incomplete or incorrect documentation on admission to inpatient rehabilitation.

Document Type

Article

Publication Date

5-19-2025

Publication Title

PM & R : the journal of injury, function, and rehabilitation

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.

DOI

10.1002/pmrj.13366

ISSN

1934-1563

PubMed ID

40386880

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