Going home is a handoff

A hospital changes hands several times a day. Nurses hand their patients to the next shift; one team of doctors signs out to another overnight. Hospitals treat these moments with care because a handoff is where information goes missing: a test that was ordered but not followed up, a medicine that was stopped but still sits on the list, a worry that one nurse had and the next one never heard.

The largest handoff of the stay gets less ceremony than any of them. On the day you go home, the hospital team passes your care to a new shift made up of you, whoever is driving you home, and a primary care office that may not yet have seen a single note from your stay. That shift didn’t train for this. It often takes over in a hurry, with a bag of belongings and a stack of papers, on a day when the patient is tired and glad to be leaving.

What happens in the weeks after

One of the clearest measurements of what goes wrong comes from a study of 400 consecutive patients sent home from the general medical service of an academic hospital. About three weeks after discharge, researchers reviewed each patient’s records and called them for a structured interview. Alan Forster and colleagues reported in 2003 that 76 patients, 19%, had an adverse event after leaving: an injury that resulted from their medical care rather than from their illness.

Doctors reviewing the cases judged 23 of those patients’ events preventable, about three in ten. And one kind of harm dominated: adverse drug events made up 66% of the adverse events the study found.

Nineteen in a hundred

Adverse events in the weeks after leaving the hospital, among 400 patients discharged home, scaled to 100.

19 of every 100

patients sent home from the general medical service of one academic hospital

Within about three weeks, 76 of the 400 patients (19%) had an adverse event: an injury caused by their medical care rather than their illness. Doctors reviewing the cases judged 23 of those patients’ events preventable, about 6 in every 100 patients.

• Adverse event judged preventable
• Adverse event, not judged preventable
• No adverse event found

Show the numbers

Figure	Out of 100	Counted among	Source
Had an adverse event after discharge	19	patients sent home from the general medical service of one academic hospital	Forster et al., 2003
Adverse event judged preventable	6	patients sent home from the general medical service of one academic hospital	Forster et al., 2003

Scaled from 76 of 400 patients (19%) with an adverse event and 23 of 400 (5.75%, shown as 6) with an event judged preventable.

Source: Forster et al., “The incidence and severity of adverse events affecting patients after discharge from the hospital,” Annals of Internal Medicine, 2003.

The study is more than twenty years old and comes from a single hospital, so its exact numbers shouldn’t be stretched too far. Later research points the same way: much of what goes wrong after discharge involves medicines, and a good share of it is the kind of thing a better handoff could catch.

Medication lists drift

A hospital stay is hard on a medication list. Doses change. A drug you take at home gets held for a few days, or swapped for a similar one the hospital stocks. New prescriptions get added on the way out. Each change makes sense at the time; the trouble is that the list you leave with has to match both what the hospital intended and what is sitting in your kitchen cabinet.

Often it doesn’t. A 2020 systematic review by Alqenae and colleagues, pooling studies of patients after discharge, found that a median of 50% of adult patients had at least one unintentional medication discrepancy after discharge: a difference in their medicines that nobody meant to create. In the seven studies that measured adverse drug events after discharge, the median rate was 19%.

Imagine your father comes home with a new prescription for a blood pressure pill. In the cabinet is a bottle of the one he took before he went in. Nobody told him to stop the old one, and nobody told him to keep it. He is tired, and both pills are for his blood pressure. That is how a discrepancy becomes a problem, and it is exactly the situation a careful discharge review exists to prevent.

The return trip

The plainest sign that a handoff didn’t hold is a return to the hospital. Across U.S. hospitals, there were 13.9 readmissions within 30 days for every 100 admissions, a rate that barely moved from 2016 to 2020, according to the Agency for Healthcare Research and Quality. For people covered by Medicare it was 17.0 per 100 in 2020.

Not every readmission is preventable, and some are exactly the right call; going back is often how a problem gets caught in time. But the number is a fair measure of how many discharges come apart within a month.

Run it like a shift change

Dr. Carol J. Scott calls the fourth step of her protocol tenacity. It adapts the high reliability principle of commitment to resilience: assume something will go wrong, and build the ability to catch it and recover before it does real harm. A good shift change is resilience in small form. The outgoing team doesn’t assume the incoming team knows anything; it says what happened, what changed and what to watch for, and it makes sure someone knows whom to call.

“Resilience gives you the ability to acknowledge and act on a potential health risk or threat, instead of ignoring it.” Dr. Scott, from the original SCOTT Protocol

You can ask for exactly that handoff. Medicare publishes a plain checklist for it, Your Discharge Planning Checklist (publication 11376), and it’s useful whatever your insurance. Organized as a shift change, its main items come out as four questions to get answered before anyone leaves the building.

What happened, and what is my status now?

Ask for written discharge instructions you can understand and a summary of your current health. The checklist tells you to bring both, along with your drug list, to your follow-up appointments, which is how the office that receives you learns what the hospital learned.

What changed?

Write a complete list of your medicines, including over-the-counter drugs, vitamins and herbal supplements, and including what you took at home before the stay. Then go through it with the staff: which ones to continue, at what dose, and which ones changed or stopped during the stay. Share the updated list with your other clinicians. This is the step that catches the two bottles in the cabinet.

What could go wrong, and what do I do then?

Ask which problems to watch for and what to do if they appear. If you or a caregiver will need a new skill, such as changing a bandage or giving a shot, the checklist says to have the staff show you and then practice it before you go. Ask too whether you’re ready for the ordinary work of home: bathing, stairs, cooking, getting to appointments and picking up prescriptions.

Who do I call?

Write down the names and phone numbers of the people to call with questions. Ask where you’ll get care after you leave, whether you’ll need equipment such as a walker, and who is arranging it. A number on a piece of paper is a small thing until it is eight o’clock on a Saturday night.

Two more questions are worth adding, though they aren’t on the Medicare list. First: are any test results still pending, and who will call me with them? A result that comes back after you’ve gone home belongs to nobody unless someone has said it belongs to them. Second: will my own doctor get a copy of the discharge summary, and when? Then call your primary care office in the first few days to check that it arrived. If it hasn’t, the handoff hasn’t happened yet, however long you’ve been home.

If you have Medicare and believe you are being sent home too soon, the same checklist explains how to ask for a fast appeal. Hospital patients with Medicare should receive a notice called the “Important Message from Medicare,” and you can call 1-800-MEDICARE with questions.

The second set of eyes

The patient is rarely the best person to run this handoff alone. They are tired, sometimes in pain, sometimes on medicines that blunt attention, and eager to be out the door. A spouse, an adult child or a friend who is not the patient can hear the instructions with fresh ears. The Medicare checklist has a section written for caregivers, and its advice is practical: write down your own questions, confirm that you can really provide the help the patient will need and ask for training if you can’t, and get prescriptions filled and errands done before the discharge rather than after.

If you are that person, a few habits make you far more useful:

• Be in the room for the discharge conversation, in person or on speakerphone, and take notes.
• Say the plan back in your own words before you leave. If you can’t, it wasn’t explained clearly enough yet, and that’s a fair thing to say.
• At home, put every bottle on the table and check each one against the new list. Set aside anything that was stopped.
• Book the follow-up appointment before the first night at home, and bring the instructions, the summary and the list.
• Write down, together, what would make you call and whom. It’s much easier to decide that on a calm afternoon than at two in the morning.

A good incoming shift checks the report because it takes the report seriously. Putting the new list beside the old bottles is the same habit, carried home.

Put it to work

This note belongs to tenacity, the fourth step of the SCOTT Protocol: plan for setbacks so one bad week never becomes a bad outcome. The field kit carries the handoff with you.

Last updated October 16, 2026. Guidance cited here was current on that date; clinical guidelines change, so check with your own clinician. See our editorial policy.