Reducing Falls Risk After Hospital Discharge: Medicines Reconciliation in Older People’s Services
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Hospital discharge is one of the highest-risk moments for falls in older people’s services. People often return home or to a care setting with reduced strength, new pain, disrupted sleep, and changed medicines. If medicines reconciliation is weak, services can end up administering duplications, missing stopped items, or failing to monitor side effects such as dizziness, sedation, and postural hypotension. This article sets out a practical, auditable approach to discharge medicines reconciliation that reduces falls risk and stands up to scrutiny. For wider context, see the Knowledge Hub index and the topic page Medicines, Frailty, Falls & Safety.
Why discharge creates a falls “risk spike”
Discharge frequently involves medication changes: new analgesia, antibiotics, anticoagulants, dose changes to antihypertensives, diuretics restarted, sedatives introduced for sleep, and PRNs added “just in case”. At the same time, people may be deconditioned, dehydrated, and anxious about mobilising. The combination increases the chance of dizziness, confusion, urgent toileting, and poor judgement around transfers—especially at night or early morning.
A strong provider response is to treat discharge as a time-limited enhanced risk period (typically 7–14 days) where medicines accuracy, side-effect monitoring, and mobility support are tightened.
Define “medicines reconciliation” as a process, not a one-off check
Many services treat reconciliation as “we got the discharge summary and updated the MAR”. That’s necessary but not sufficient. A defensible process includes: confirming what has changed, ensuring supply and administration routes are correct, monitoring expected side effects, and ensuring staff practice aligns with new risks.
Minimum reconciliation outputs
- An accurate current medicines list (including dose, timing, route, indications).
- A clear “changes record” showing started, stopped, and changed items, including reasons where known.
- Supply assurance so missed doses don’t occur because items are unavailable or packaging is wrong.
- Side-effect monitoring plan linked to falls risk (drowsiness, dizziness, confusion, toileting urgency).
- Staff briefing so the day-to-day routine changes (supervised transfers, toileting prompts, hydration checks) actually happen.
Operational steps: a practical reconciliation workflow that works on shift
Services can implement a simple, standard workflow that is triggered the same way every time.
Step 1: Gather and compare sources
Use at least two sources where possible (e.g., discharge summary + medicines brought in / pharmacy printout / GP list). Identify discrepancies early rather than assuming one document is correct. Where there is conflict, escalate to the prescriber or community pharmacy for confirmation and record the action taken.
Step 2: Create a “change log” that staff can use
A change log translates clinical documents into operational reality. It should list what is new, what stopped, and what changed, plus the “watch outs” (e.g., “new opioid: monitor sedation and constipation”; “antihypertensive dose increase: monitor dizziness on standing”).
Step 3: Tighten administration controls in the first 7–14 days
- Protected rounds: reduce interruptions during medicines rounds while new regimes are bedding in.
- Double-check high-risk items: anticoagulants, insulin, opioids, sedatives, and any new diuretic schedule.
- PRN governance reset: confirm PRN indications and thresholds, and brief staff that PRN must not become routine.
- Timing plan: note predictable risk windows (e.g., diuretics + urgent toileting; sedatives + night transfers).
Step 4: Build side-effect monitoring into daily routines
For the enhanced risk period, agree simple prompts staff can apply consistently: “more drowsy than usual?”, “new unsteadiness?”, “dizziness when standing?”, “confusion?”, “new urgency at night?”, “reduced intake?”. Recording does not have to be long, but it must be consistent enough to show patterns and justify escalation.
Step 5: Set escalation triggers that are easy to follow
Escalation triggers reduce hesitation and variation between staff members. Examples include:
- Any fall or near fall within 14 days of discharge.
- New or worsening dizziness, faintness, or “legs giving way”.
- Excessive daytime sleepiness or marked sedation after dose changes.
- Repeated PRN sedatives or opioids (>3 uses in 7 days) or any PRN linked to unsteadiness.
- Reduced oral intake or signs of dehydration while on diuretics or laxatives.
Operational example 1: Duplicate sedatives after discharge
Context: A person returns from hospital with a new sleep medicine started. The home already has a PRN hypnotic on the MAR. Night staff administer both on two consecutive nights and the person is found extremely drowsy the next morning, with a near fall during toileting.
Support approach: The service uses a reconciliation comparison step: discharge meds are compared to the current MAR before first administration. The duplication is identified, and the prescriber/pharmacy is contacted for clarification and a stop instruction. PRN protocols are re-briefed to staff.
Day-to-day delivery detail: The team leader adds a temporary “enhanced monitoring” note: supervised night transfers, morning checks for sedation/unsteadiness, and hydration prompts. The MAR is updated with clear guidance and the PRN record requires effect/sedation documentation.
How effectiveness is evidenced: The change log shows the duplication and the resolution action. The near fall is recorded with learning outcomes. A short audit confirms staff are documenting PRN rationale and outcomes correctly, and no repeat incidents occur.
Operational example 2: Postural hypotension after antihypertensive change
Context: Discharge summary indicates an antihypertensive dose increase. Over the next three days, staff notice the person is “wobbly” on standing and they fall when rising quickly to answer the door.
Support approach: The service applies agreed escalation triggers: dizziness on standing + fall within 14 days of discharge prompts clinical review. Staff implement a “slow rise” routine and provide support at predictable risk times.
Day-to-day delivery detail: Staff prompt the person to sit on the bed edge before standing, and they support transfers until symptoms settle. They record dizziness consistently in daily notes and medicines round observations. A GP/pharmacist review is requested using a structured template: what changed, observed effects, fall incident, and suggested options (timing/dose review).
How effectiveness is evidenced: Falls and dizziness episodes reduce after timing is adjusted. Records show the review request, outcome, and updated care plan. A falls meeting log demonstrates learning and action tracking.
Operational example 3: Diuretic timing and night-time toileting falls
Context: A diuretic is restarted on discharge. It is administered later than intended due to staffing pressures, leading to repeated urgent toileting overnight and a fall at 03:20.
Support approach: The service tightens medicines timing and links it to the falls plan: diuretic timing is prioritised earlier, and overnight toileting support is scheduled during the predictable risk window.
Day-to-day delivery detail: The rota allocates a specific staff member to support toileting calls during high-risk periods. Staff ensure call bell access and rapid response. Hydration is encouraged earlier in the day with balanced continence planning. The person’s care plan includes an explicit night routine and safe transfer support.
How effectiveness is evidenced: Night-time falls and urgent toileting incidents reduce. The service can show the timing correction, staff briefing record, and a brief audit of medicines administration times in the first 14 days post-discharge.
Governance: evidence that commissioners and CQC can follow
Reconciliation becomes defensible when it is systematic and traceable. Providers can evidence control through:
- Discharge reconciliation checklist: completed for every discharge, filed consistently.
- Change log and staff briefing record: who briefed, when, and what changed operationally.
- Enhanced monitoring plan: defined period and prompts, then stepped down when stable.
- Audit sampling: monthly sample of discharges checking MAR accuracy, PRN controls, and escalation actions.
- Falls meeting action log: shows learning and sustained practice changes, not one-off fixes.
Explicit expectations
Commissioner expectation: The provider can demonstrate a reliable discharge medicines reconciliation process that reduces avoidable harm, includes clear escalation triggers, and is evidenced through audit and measurable reduction in repeat falls/near-falls post-discharge.
Regulator / Inspector expectation (e.g. CQC): Medicines are managed safely with accurate records, appropriate monitoring after changes, and effective learning from incidents. Inspectors can trace how a discharge change was identified, implemented, monitored, and reviewed when risk increased.
What good looks like in practice
In strong services, staff can explain what changed on discharge, what they are watching for, and what they do differently during the enhanced risk period. Documentation shows a clear chain: discharge information → reconciliation → operational plan → monitoring → escalation/review → updated practice. That consistency is what reduces falls risk and demonstrates real quality assurance.
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