education ·
Nearly 1 In 4 Hospital Stays Had An Adverse Event. Here's The Card We'd Carry
Medication is the biggest category of hospital harm, and the fix is a list somebody can read. Here is what the evidence does and does not support.
Nearly one admission in four involves something going wrong, and the largest single category is medication. That is not a scare statistic, it is the finding of a 2023 New England Journal of Medicine study, and it points at something you can actually prepare for.
So here is the card we would carry, and, more usefully, how strong the evidence is behind each line on it.
The number this is built on
Trained nurses screened a random sample of 2,809 admissions across 11 Massachusetts hospitals in 2018, with physicians confirming each event (Bates et al., New England Journal of Medicine, 2023).
At least one adverse event occurred in 23.6% of admissions. Of the 978 events, 222 were judged preventable and 316 reached a severity of serious or higher. Adverse drug events were the most common type at 39.0%, ahead of surgical or procedural events at 30.4%, nursing-care events at 15.0%, and healthcare-associated infections at 11.9%.
Medication is the biggest slice. It is also the one where what you bring through the door changes what the receiving team knows.
Does a list actually work
This is where we have to be careful, because the intuitive answer and the evidence are not quite the same.
Medication reconciliation, the formal process of building an accurate list and checking it against what is prescribed, has been studied a lot. A systematic review of 26 controlled studies found it reduced medication discrepancies in 17 of 17 studies that measured them, reduced potential adverse drug events in 5 of 6, and reduced adverse drug events in 2 of 2 (Mueller et al., Archives of Internal Medicine, 2012). Only 6 of the 26 studies were rated good quality, and the best results came from interventions that used pharmacy staff intensively and targeted high-risk patients.
Then Cochrane looked at randomised trials only: 25 trials, 6,995 participants (Redmond et al., Cochrane Database of Systematic Reviews, 2018).
| Outcome | Result | Certainty |
|---|---|---|
| At least one medication discrepancy | RR 0.53 (0.42 to 0.67) | Very low |
| Preventable adverse drug events | RR 0.37 (0.09 to 1.57) | Very low |
| Adverse drug events | RR 1.09 (0.91 to 1.30) | Low |
| Unplanned rehospitalisation | RR 0.72 (0.44 to 1.18) | Moderate, probably little or no difference |
Read that table honestly. Reconciliation reliably fixes discrepancies on paper. Whether that translates into fewer people actually harmed is, in Cochrane’s assessment, uncertain.
The impact of medication reconciliation interventions, in particular pharmacist-mediated interventions, on medication discrepancies is uncertain due to the certainty of the evidence being very low.
Redmond et al., Cochrane Database of Systematic Reviews, 2018
We are including that because it is true, and because a card sold as proven protection would be exactly the overclaiming we criticise elsewhere. What the card does is make the correct information available. That is worth doing on its own terms.
The participation finding
Among 788 recently hospitalised patients whose medical records were reviewed alongside a survey about how involved they had been, those who participated most in their care were about half as likely to have had an adverse event, with an adjusted odds ratio of 0.49 (95% CI 0.31 to 0.78) (Weingart et al., International Journal for Quality in Health Care, 2011).
That is a striking association and it is observational. People who ask more questions in hospital differ from people who do not, in ways that include how sick they are, how educated, how well they feel, and whether somebody is there with them. None of that is controlled away by an odds ratio.
So the honest reading is that participation travels with better outcomes, and the direction of cause is not established. It is still the cheapest thing on this list.
The card
One index card, written before you go, carried in a pocket, and a photo of it on the phone of whoever is with you.
Side one, what you take. Every prescription with dose and timing. Every over-the-counter medicine, including painkillers and antacids. Every supplement, because many interact and most people do not mention them. Anything you stopped in the last month and when. Allergies and what the reaction actually was, since “allergic to penicillin” meaning a childhood rash is a different fact from anaphylaxis.
Side two, who and what. Your usual pharmacy. Your regular prescriber’s name and number. Conditions somebody arriving cold would need to know. The name and number of the person who speaks for you if you cannot. Whether you have an advance directive and where it is.
That is the whole card. It takes twenty minutes once and gets updated when something changes.
The questions worth asking, which cost nothing and are where the participation finding points: what is this medicine for, what should it look like, has anything changed since yesterday, and who do I ask if something seems wrong.
What we are and are not saying
| Claim | Our line |
|---|---|
| A card prevents hospital harm | Not proven. Cochrane rates the harm evidence uncertain |
| Nearly a quarter of admissions had an adverse event | Yes, 23.6% in 2,809 admissions |
| Medication is the biggest category | Yes, 39.0% of adverse events |
| Reconciliation reduces discrepancies | Yes, 17 of 17 studies, though at very low certainty in randomised trials |
| It reduces rehospitalisation | Probably not, on moderate-certainty evidence |
| Participating in your care halves your risk | Associated, not proven. The study is observational |
| This replaces what the hospital should do | No. The best results came from heavy pharmacy involvement |
| Hospitals should be avoided | Never |
Where the design shows up
The thing that goes wrong most often is not a scalpel in the wrong place. It is a handover.
Somebody knows a fact, and the next person does not. That is what a discrepancy is: a true thing that failed to travel. The reason a medication list works at all, to whatever degree it works, is that it turns a fact living in one person’s memory into an object that can be handed over.
Which is a reasonable description of what writing was invented for. The oldest technology in this article is a card with a list on it, and against a system where information has to survive three shift changes, it is still the right tool.
“Write the vision and inscribe it on tablets, that the one who reads it may run.” Habakkuk 2:2, NASB
The verse carries the conviction. Two thousand eight hundred and nine admissions carry the number.
What to do this week
Write the card. Not before a hospital stay, now, while nobody is ill and the information is easy to gather, because the admissions that matter most are the ones nobody scheduled.
Put a photo of both sides on your phone and on the phone of whoever would come with you. Keep the physical card where you would grab it, and set a reminder to check it whenever a prescription changes.
If you are caring for an older relative, do theirs too, and bring the drafting into an appointment rather than reconstructing it from bottles on a worktop. That conversation often surfaces a medicine nobody realised was still being taken, which is the problem described in the prescribing cascade.
Read this next: why the famous death-toll statistic does not survive scrutiny, and what the real numbers are: one Johns Hopkins estimate ranks this killer third. How a side effect turns into a second prescription: the prescribing cascade. And what withdrawal looks like when something is stopped: the rebound effect.
Sources
- Bates DW, Levine DM, Salmasian H, et al. “The Safety of Inpatient Health Care.” The New England Journal of Medicine, 2023;388(2):142-153. https://pubmed.ncbi.nlm.nih.gov/36630622/
- Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. “Hospital-based medication reconciliation practices: a systematic review.” Archives of Internal Medicine, 2012;172(14):1057-1069. https://pubmed.ncbi.nlm.nih.gov/22733210/
- Redmond P, Grimes TC, McDonnell R, Boland F, Hughes C, Fahey T. “Impact of medication reconciliation for improving transitions of care.” Cochrane Database of Systematic Reviews, 2018;8(8):CD010791. https://pubmed.ncbi.nlm.nih.gov/30136718/
- Weingart SN, Zhu J, Chiappetta L, et al. “Hospitalized patients’ participation and its impact on quality of care and patient safety.” International Journal for Quality in Health Care, 2011;23(3):269-277. https://pubmed.ncbi.nlm.nih.gov/21307118/
Article metadata retrieved from PubMed. Photograph from Pexels. Scripture quoted from the New American Standard Bible.
Educational content from True Health Solutions. We do not diagnose or prescribe, and nothing here is a substitute for care from someone who knows your history. The body heals. We write about what supports that design.
Questions people ask
- How common are hospital adverse events?
- In a 2023 study of 2,809 admissions across 11 Massachusetts hospitals, at least one adverse event occurred in 23.6%. Adverse drug events were the largest single category at 39.0% of all events, and 22.7% of events were judged preventable.
- Does carrying a medication list actually help?
- The evidence is real but weaker than you would hope. A systematic review of 26 controlled studies found medication reconciliation reduced discrepancies in 17 of 17 studies that measured them. A Cochrane review of 25 randomised trials found a risk ratio of 0.53 for having at least one discrepancy, but rated that evidence very low certainty.
- Does it reduce actual harm, not just paperwork errors?
- That is where it thins out. The Cochrane review found the effect on adverse drug events uncertain, with a risk ratio of 1.09 and a confidence interval crossing 1, and concluded reconciliation probably makes little or no difference to unplanned rehospitalisation.
- Does speaking up help?
- It is associated with less harm. Among 788 recently hospitalised patients whose charts were reviewed, those who participated most in their care were about half as likely to have had an adverse event, with an adjusted odds ratio of 0.49. That is observational, so it cannot prove the participation caused the difference.
- Is this a substitute for the hospital doing its job?
- No. The best results in the reconciliation research came from interventions that leaned heavily on pharmacy staff, which is the hospital's work rather than yours. A card helps the system do its job. It does not replace it.
