What One Patient’s Story Teaches Us About Safer Discharge Practices

After a major surgery, patients are often sent home in a vulnerable state - tired, in pain, and sometimes disoriented due to medication. For one woman, this experience became a challenge as she tried to manage her medications with limited support and unclear instructions. Her story highlights a critical gap in patient care: the need for better written and visual discharge resources to empower patients to manage their health confidently at home.

A 62-year-old woman from provincial New Zealand underwent major surgery at a city hospital. She was initially expected to stay for just one night, but due to several issues, her stay was extended. When she was discharged after two nights, she was still in significant discomfort, heavily medicated, and exhausted.

She left the hospital with a discharge summary and a script for 8 different medications, which she took to the pharmacy, receiving a large box of different medicines to take home. One of her medications required self-injection, something she had only administered once in the hospital with nursing supervision.

Without a support person to assist her at home and utterly exhausted, she was left to figure out her medications on her own. Yes, she had received written discharge notes, but there was a lot of complexity about the timing, dosage, length of time to take each medicine, which were to be taken with food and which medicines should not be taken together. What could go wrong? A lot.

The solution? This patient created a clever visual checklist to track what she needed to take and when - a system that helped her stay on top of her medications and avoid mistakes. But should managing post-discharge care really be this difficult?

Her discharge instructions:

Her box of medications:

Her self-made checklist:

Even though this patient is highly health-literate, organised, and speaks English as her first language, she struggled to manage her medications safely after discharge. The complexity of post-discharge care highlights a major gap in patient communication - one that can lead to adverse drug events, confusion, and stress [2].

This raises an important question: if someone with these advantages found it challenging, how much harder is it for patients with limited health literacy, language barriers, or cognitive challenges?

When discharge instructions are unclear or incomplete, the consequences can be serious. Studies show that around 12-20% of patients experience adverse drug events after discharge, often due to confusion about their medication regimen [1,4,5]. Misunderstandings can lead to missed doses, incorrect medication use, and harmful side effects - all of which can result in readmissions or worse [2].

But this isn’t just a patient safety issue, it’s also an opportunity. Clear, well-structured discharge communication can improve patient outcomes, reduce anxiety, and build trust between patients and healthcare providers.

This experience is not unique. Many patients report difficulties understanding discharge information due to [3]:
🔹 Complex medical terminology
🔹 Fatigue and pain impacting cognitive function
🔹 Lack of visual aids to simplify instructions

The good news? Hospitals that prioritise discharge communication are making a real difference. At Cemplicity, we’ve seen how hospitals like Mercy Hospital in New Zealand transform their discharge experience by co-designing resources with patients.

Mercy Hospital developed a discharge take-home brochure that clearly outlines medication schedules, potential side effects, and recovery instructions, presented in a simple, visually engaging format. But they didn’t stop there. They tested and refined the resource over a year, incorporating patient feedback to ensure it was practical and easy to follow.

The result? Mercy Dunedin has an impressive Net Promoter Score (NPS) of 94 out of 100, making it one of our top-performing hospitals globally.

View Mercy's discharge brochure and read their full story here.

If hospitals want to reduce post-discharge risks and improve patient experience, there are actionable steps they can take:

Patients won’t always remember every instruction they receive at discharge, but they will remember how they felt - safe, supported, and equipped to take care of themselves. When hospitals take the time to provide clear, practical, and patient-centred discharge resources, they don’t just prevent adverse events. They give patients the confidence to manage their recovery and build lasting trust in their healthcare providers.

References:

1. World Health Organization (WHO). (2019). Medication safety in polypharmacy. WHO Universal Health Coverage and System Development Series No. 11. Retrieved from https://www.who.int/docs/default-source/patient-safety/who-uhc-sds-2019-11-eng.pdf

2. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital discharge. Journal of General Internal Medicine [Internet]. 2005 Apr;20(4):317–23. Available from: https://link.springer.com/article/10.1111/j.1525-1497.2005.30390.x

3. Raising the Bar on the National Patient Experience Survey: Report Findings and Recommendations / Report by #ogilvychange Tātou Ogilvy & Mather; Prepared for Health Quality & Safety Commission New Zealand. [Internet]. Govt.nz. 2025 [cited 2025 Jan 22]. Available from: https://ndhadeliver.natlib.govt.nz/delivery/DeliveryManagerServlet?dps_pid=IE28351710

4. Gurwitz, J. H., Field, T. S., Avorn, J., McCormick, D., Jain, S., Eckler, M., Benser, M., Edmondson, A. C., & Bates, D. W. (2013). Adverse drug events post-hospital discharge in older patients. Journal of the American Geriatrics Society, 61(5), 754-761. https://pmc.ncbi.nlm.nih.gov/articles/PMC4446728/

5. Picton, C., & Wright, H. (2012). Keeping patients safe when they transfer between care providers – getting the medicines right. Final report. London: Royal Pharmaceutical Society. https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Publications/Keeping%20patients%20safe%20transfer%20of%20care%20report.pdf