One Follow-Up Call That Prevented a Discharge Medication Mix-up

The Challenge

An elderly patient discharged from a hospital stay and should have been sent home with a new Stiolto inhaler. 24 hours following discharge, a Care Continuity Navigator reached out with a follow-up call, at which point the patient’s caregiver indicated that the new inhaler was not received at discharge.

The caregiver also indicated that the patient was previously on Stiolto but was recently switched to a Trelegy inhaler by his pulmonologist.

The Navigator reviewed the patient’s chart and confirmed that both inhalers were listed in the discharge instructions, creating unnecessary confusion for the patient.

What We Did

Following the agreed-upon escalation protocol, the Navigator promptly engaged the hospital’s Care Coordination team to address the medication concern. Care Coordination reviewed the issue and escalated it to the discharging provider for clarification. The discharging provider then confirmed the appropriate medication and issued orders for the patient to resume Trelegy as prescribed before admission.

The Impact

• Potential medication errors were avoided through timely escalation and provider confirmation.
• Care teams aligned on the patient’s discharge plan, preventing confusion during the transition home
• Avoided a potential hospital readmission by catching a missing medication and gap in the patient’s care plan

Why It Matters

Medication issues are one of the most common and preventable drivers of hospital readmissions, contributing to roughly 20% of 30-day readmissions. When medication instructions are unclear or conflicting, patients and families may struggle to manage treatment at home, increasing the risk of complications and unnecessary hospital visits. Quickly identifying and resolving medication discrepancies helps ensure patients have the clarity and support they need to recover safely at home.