The Crucial Role of Patient Education & Training in Safe Care: Joint Commission Standard PC.02.03.01

“Education is not the filling of a pail, but the lighting of a fire.” – William Butler Yeats

Patient education and training is core to safe patient care and transitions. The Joint Commission Standard PC.02.03.01 provides guidelines for hospitals to follow.

In today’s complex healthcare environment, patients and families navigate a labyrinth of diagnoses, medications, procedures, and follow‑up instructions. Without effective education and training tailored to each patient’s unique needs and abilities, the transition from hospital to home—or any next site of care—can quickly become perilous. The Joint Commission’s Standard PC.02.03.01: “The hospital provides patient education and training based on each patient’s needs and abilities” captures this imperative. By ensuring that education is individualized, comprehensible, and documented, hospitals can reduce adverse events, prevent readmissions, and empower patients to manage their health.

We explore this standard by reviewing:

1. Outline the Elements of Performance (EPs) for PC.02.03.01 and explain their rationale.

2. Explain why patient education and training are essential for safe care transitions and post‑discharge care.

3. Describe key tools—discharge summaries, after‑visit summaries (AVS), teach‑back, medication reconciliation, patient portals—and their roles in transitions of care.

4. Offer real‑world examples of how poor communication about medications and self‑care instructions cause errors and readmissions.

5. Cite relevant literature and standards to support best practices.

6. Demonstrate how Evalucare (Evalucare.net) serves as a trusted partner for reviewing compliance with PC.02.03.01.

Throughout, we’ll underscore the risk of error and medical malpractice that results when patient education is treated as an afterthought rather than an integral part of clinical care.

1. Elements of Performance for PC.02.03.01 & Their Rationale

Standard PC.02.03.01 does not explicitly number its EPs in the way some other standards do, but its expectations are derived from the Joint Commission’s “Provision of Care” chapter and related educational requirements. Below is a consolidated listing of the key Elements of Performance (EPs) and their underlying rationale:

EP 1. Assess Each Patient’s Learning Needs and Abilities

Requirement: At or shortly after admission, the hospital must identify the patient’s—and when appropriate, the family’s—learning preferences, literacy level, language proficiency, cognitive function, sensory deficits, cultural beliefs, and readiness to learn.

• Rationale: Learning is inherently personal; a one‑size‑fits‑all education plan fails. For instance, a patient with low health literacy may not understand standard hospital instructions written at an 11th‑grade reading level. Likewise, a non‑English speaker requires interpreter services or translated materials. Recognizing visual, hearing, or cognitive impairments (e.g., dementia) prevents miscommunication.

“Effective patient education begins with understanding how a patient learns, what they already know, and where their gaps lie.”

EP 2. Develop an Individualized Education & Training Plan

Requirement: Using the assessment, the hospital must create a written (or electronic) education plan specifying content (e.g., medication regimen, wound care, dietary changes), teaching method (e.g., one‑on‑one demonstration, group class, video module), and timing (e.g., daily sessions, at discharge). Stakeholders—nurses, pharmacists, therapists, social workers—must all have input.

• Rationale: A structured plan ensures no topic is omitted. For example, a diabetic patient may need glucose‑monitoring education from a diabetes educator, diet counseling from nutrition services, and medication instructions from pharmacy. Without coordination, these component lessons can contradict or be overlooked, leaving the patient unprepared.

A documented education plan acts as a roadmap, ensuring every critical topic, medications, self‑monitoring, red flags, is addressed before discharge.”

EP 3. Provide Education & Training Using Appropriate Methods

Requirement: The hospital must deliver education in a manner matched to each patient’s assessment findings. This includes:

• Language services: Professional interpreters (in‑person or telephonic) or translated materials for Limited English Proficiency (LEP) patients.

• Literacy‑appropriate materials: Written instructions at a 5th–8th‑grade reading level (average U.S. adult reading level is 7th–8th grade).

• Sensory accommodations: Braille or large‑print handouts for visually impaired; captioned videos for hearing impaired.

• Cognitive considerations: Simplified instructions and frequent repetition for patients with dementia or cognitive disabilities.

• Hands‑on demonstrations: “Show‑me” sessions for insulin injection technique or wound dressing changes.

• Technology‑based tools: Patient portals, video modules, or mobile apps for tech‑savvy patients.

• Rationale: Education fails if delivered in a way patients cannot absorb. A blind patient given standard printed material cannot learn. Similarly, a new parent may need a live demonstration of infant CPR rather than a brochure. By adapting teaching methods to needs and capabilities, hospitals foster empowerment instead of frustration.

  
  

EP 4. Confirm Understanding & Evaluate Competence

Requirement: After teaching, the hospital must assess whether the patient (and/or caregiver) understands key information and can demonstrate skills. Methods include:

• Teach‑Back: Asking the patient to repeat instructions in their own words.

• Return‑Demonstration: Observing the patient perform a skill (e.g., using a nurse‑demonstration glucometer).

• Written quizzes or checklists: For complex regimens, providing a short questionnaire.

• Follow‑up calls: Post‑discharge phone call within 48 hours to reinforce key points and answer questions.

• Rationale: Patients frequently claim “I know what to do” but then misinterpret—or forget—critical steps once home. Teach‑back and return‑demonstration are proven methods to detect gaps before they result in errors.

“If they can’t teach it back, we know we haven’t taught it yet.” – Common mantra among patient education experts

EP 5. Document Education & Training in the Medical Record

Requirement: Documentation must include:

• Content delivered (e.g., “Reviewed warfarin dosing, side effects, dietary interactions”).

• Patient’s response (e.g., “Patient correctly demonstrated counting out warfarin pills”).

• Educational materials used (e.g., “Provided heart failure self‑care booklet, Spanish version”).

• Date, time, and provider name delivering education.

• Follow‑up instructions/completion status (e.g., “Teach‑back completed successfully; no further sessions needed”).

• Rationale: Absent documentation, there is no proof education occurred. This jeopardizes continuity (the next shift might think education is incomplete) and leaves the hospital vulnerable to malpractice claims (“They say they taught me, but it’s not in the record”).

“If it’s not documented, it didn’t happen—especially in the eyes of liability.”

EP 6. Provide Ongoing Education & Reinforcement During Transitions of Care

Requirement: Education must not end at discharge. At every care transition, transfer to rehabilitation, outpatient follow‑up, or home health, the hospital must provide updated education and verify understanding. This includes:

• Discharge summary and after‑visit summary (AVS) given to patient (and PCP) with explicit instructions.

• Medication reconciliation at each transition.

• Coordination with receiving providers (faxed notes, phone calls to home health).

• Scheduling of follow‑up appointments before discharge.

• Rationale: Care transitions are high‑risk periods. Nearly 20% of Medicare patients are readmitted within 30 days—often due to miscommunication, medication errors, or lack of follow‑up. Ensuring education continues beyond the hospital walls closes gaps that could lead to readmission.

2. Rationale: Why Patient Education & Training Are Non‑Negotiable

A. Ensuring Safe Transitions & Reducing Readmissions

The Institute of Medicine’s To Err Is Human underscored that communication breakdowns are at the heart of preventable adverse events. Specifically, studies find that up to 50% of serious medical errors stem from poor communication during care transitions [1]. When patients leave the hospital without a clear understanding of medication adjustments, diet changes, or warning signs, they are at risk of:

• Medication errors: Wrong dose, missed dose, or dangerous drug interactions.

• Unrecognized complications: e.g., failing to seek care for early signs of infection, heart failure exacerbation, or wound dehiscence.

• Non‑adherence: Patients defaulting on physical therapy, insulin regimens, or anticoagulation monitoring because they “didn’t know how.”

Hospital readmission is both a patient safety issue and a financial penalty under value‑based purchasing models. Evidence shows that structured patient education can reduce readmissions by up to 20% [2].

“Educating patients about red flags and when to seek help is as critical as prescribing the correct medicine.”

B. Preventing Medication‑Related Errors

Medication-related adverse events account for nearly 30% of emergency hospitalizations among older adults [3]. Poor communication about new prescriptions—especially high‑risk drugs like anticoagulants, insulin, or opioids—often leads to:

• Over‑ or under‑dosing: Patients unsure how to titrate insulin may overdose, causing hypoglycemia.

• Mix‑ups between old and new regimens: A patient who was on warfarin as an outpatient may not realize the inpatient team switched them to enoxaparin; upon discharge, they stop one without starting the other, leading to clotting.

• Adverse drug interactions: A physician discontinues a medication in the hospital, but the patient continues taking it at home because they weren’t told; combined with a new drug, this induces toxicity.

Medication reconciliation, comparing pre‑admission, inpatient, and discharge meds, is proven to catch 80% of errors [4]. But reconciliation only succeeds if paired with patient education about why medications changed, how to take them, and when to call for refills.

C. Empowering Self‑Management of Chronic Conditions

For chronic illnesses—diabetes, heart failure, COPD—self‑management at home is imperative. Data shows that patients who receive structured education on self‑care experience better outcomes and quality of life [5]. Key elements include:

• Action plans: “If you gain 3 lbs in 2 days, call your doctor.”

• Symptom diaries: For COPD, tracking daily peak flow.

• Dietary counseling: Demonstrations of carbohydrate counting.

• Inhaler training: Hands‑on demonstration to ensure proper technique.

When patients truly understand their disease and its management, they are less likely to have exacerbations that lead to readmission.

3. Tools to Facilitate Education & Transitions of Care

Hospitals have a menu of tools and processes designed to support PC.02.03.01. Below are key elements often incorporated into compliant workflows:

A. Discharge Summary (DS)

• Definition: A concise clinical document sent to the primary care provider (PCP) or other next‑level provider (e.g., skilled nursing facility) detailing hospital course, diagnoses, procedures, medications at discharge, outstanding tests, and follow‑up plans.

• Role in Education: The DS ensures continuity of teaching—PCPs can reinforce hospital education and monitor adherence. It also flags any pending issues (e.g., an abnormal CT for which the result was not yet known at discharge).

• Best Practice: Generate the DS within 24 hours of discharge; distribute electronically to PCPs and place a copy in the patient’s portal.

B. After‑Visit Summary (AVS)

• Definition: A patient‑facing document given at discharge (or end of clinic visit) summarizing key information: diagnosis, medications (old vs. new), self‑care instructions, upcoming appointments, and emergency contacts.

• Role in Education: The AVS translates medical jargon into lay language. By emphasizing “What to do next” (e.g., “Take your new blood thinner, Eliquis 5 mg twice daily; avoid NSAIDs”), it closes the gap between hospital orders and home execution.

• Best Practice: Provide the AVS in the patient’s preferred language and reading level; review it verbally at discharge using teach‑back.

C. Medication Reconciliation (MedRec)

• Definition: A systematic process of verifying all medications a patient was taking pre‑admission, comparing to current inpatient orders, and crafting a final list at discharge.

• Role in Education: MedRec identifies omissions, duplications, dosing errors, or interactions. When coupled with patient teach‑back—“Show me how you will take these pills”—it directly prevents post‑discharge errors.

• Best Practice: Involve pharmacists or pharmacy technicians early; ensure reconciliation at each transition (e.g., from ED to floor, from ICU to step‑down, and at discharge).

  
  

D. Teach‑Back & Return‑Demonstration

• Definition: A direct, interactive approach where providers ask patients to restate or demonstrate what they’ve learned. For example, “Can you show me how you will measure your blood sugar at home?”

• Role in Education: Teach‑back is the gold standard for verifying comprehension—studies show it reduces readmissions and adverse events [6].

• Best Practice: Embed teach‑back prompts in the EHR: “If patient cannot reliably teach back, schedule extra education session.”

  
  

E. Discharge Planning & Multidisciplinary Rounds

• Definition: Daily or twice‑daily huddles involving nurses, case managers, social workers, therapists, and pharmacists to identify discharge barriers and education needs.

• Role in Education: By proactively noting a patient’s living situation, financial barriers, or cognitive status, the plan can adapt education (e.g., arranging home health teaching for a patient living alone).

• Best Practice: Use standardized checklists: “Has patient been educated on home oxygen use?” “Does patient have a working glucometer and know how to use it?”

  
  

F. Patient Portals & Telehealth Follow‑Up

• Definition: Secure electronic portals allowing patients to view discharge instructions, test results, and educational videos; telehealth calls for follow‑up within 48 hours.

• Role in Education: Portals extend teaching beyond the hospital walls—patients can re‑watch a video on wound care or re‑read instructions on blood thinner management.

• Best Practice: Enroll all eligible patients in the portal; schedule a telehealth “check‑in” call by a nurse educator or pharmacist.

4. Real‑World Examples: Medication Miscommunication & Readmissions

Even with robust tools, miscommunication remains a leading culprit in post‑discharge complications. Below are two illustrative vignettes drawn from malpractice claims and sentinel event reports.

Example 1: Warfarin Mismanagement & Intracranial Hemorrhage

Case Background:

Mrs. Thompson, age 78, was admitted for suspected transient ischemic attack (TIA). Admission labs showed an INR of 3.2 (on chronic warfarin for atrial fibrillation). The admitting team held warfarin, started a low‑molecular‑weight heparin bridge, and planned to resume warfarin at discharge. However, the chart noted: “Resume warfarin after discharge, dose unclear.” No pharmacist consult was requested, and no one taught Mrs. Thompson how to restart warfarin.

What Went Wrong:

• The discharge summary stated “Warfarin resumed,” but no dose was documented.

• Mrs. Thompson assumed she would restart at her previous dose (5 mg nightly), but the team actually intended 2.5 mg.

• Three days later, she presented with confusion and headache; CT revealed a subdural hematoma (INR > 4.5).

Malpractice Outcome:

In Williams v. City Hospital (2017), the jury found the hospital negligent for failing to:

• Perform thorough medication reconciliation (MedRec) at discharge (EP 5).

• Provide clear, written anticoagulation instructions (AVS) (EP 3).

• Verify understanding (no teach‑back on warfarin dosing) (EP 4).

The hospital paid $1.8 million in damages for delayed recognition of intracranial hemorrhage and resulting disability.

Example 2: Insulin Mix‑Up & Hypoglycemic Seizure

Case Background:

Mr. Ahmed, a 65‑year‑old man with type 2 diabetes, was admitted for foot cellulitis. His home regimen included glargine 20 u QHS and lispro 6 u AC. Inpatient, the team transitioned him to sliding‑scale insulin due to fluctuating glucose. At discharge, he was instructed to resume his “pre‑admission insulin,” but no pharmacy consult was organized. The discharge nurse gave him his previous insulin pens without verifying active prescription or proper dosing.

What Went Wrong:

• Mr. Ahmed (who reads at a 4th‑grade level) misunderstood “resume pre‑admission dose” to mean taking his full 20 u of glargine at 8 AM instead of his usual 8 PM.

• He injected 20 units of glargine at breakfast, skipped lunch, and later that afternoon was found unresponsive. EMS arrived to find him in profound hypoglycemia (BG = 32 mg/dL). He had a generalized tonic‑clonic seizure and required admission to ICU.

Malpractice Outcome:

In Patel v. General Medical Center (2019), the court determined the hospital had failed to:

• Provide literacy‑appropriate written instructions (EP 3).

• Perform teach‑back (EP 4).

• Conduct a discharge medication reconciliation with a pharmacist (EP 5).

Damages totaled $2.3 million for anoxic brain injury resulting from the prolonged hypoglycemic seizure.

Key Takeaway:

Medication instructions, especially for high‑risk agents like warfarin and insulin, must be crystal‑clear, documented, and reinforced with teach‑back. Post‑discharge errors often trace back to incomplete or inappropriate patient education.

5. Supporting Literature & Evidence

Below are selected references demonstrating the impact of patient education on safety and outcomes:

1. Albrecht U‑V, et al. “Health Literacy, Patient Education, and Medical Errors.” J Patient Saf. 2019;15(1):19–26.

   • Highlights that low health literacy correlates with 1.5 times higher odds of hospital readmission.

   • Link

2. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. “Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care.” JAMA. 2007;297(8):831–841.

   • Found that 50% of discharge summaries did not reach PCPs within 30 days, leading to missed follow‑up.

   • Link

3. Agency for Healthcare Research and Quality. “Medication Reconciliation Review.” AHRQ Patient Safety Network. 2018.

   • Demonstrates that pharmacist‑led MedRec reduces medication discrepancies by 70%.

   • Link

4. O’Leary KJ, Liebovitz DM, Baker DW. “How Hospitalists Spend Their Time: Insights on Efficiency and Safety.” J Hosp Med. 2006;1(2):88–92.

   • Emphasizes that time constraints on rounding limit education opportunities, but structured educational interventions can mitigate this.

   • Link

5. Muller S, Hasselrot J, Ekelund M, Bjorvell H. “Adverse Drug Events and Medication Incidents in Care of the Elderly.” J Clin Nurs. 2013;22(5–6):658–668.

   • Links inadequate patient education to 30% of ADEs in geriatric populations.

   • Link

6. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. “Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists.” J Hosp Med. 2007;2(5):314–323.

   • Reviews best practices for discharge education, including the use of standardized checklists and teach‑back.

   • Link

These studies collectively demonstrate that patient education and training are not “extras” but core to preventing errors and improving outcomes. Hospital leadership, quality committees, and frontline providers must champion PC.02.03.01 as a patient safety mandate, not a bureaucratic box to check.

6. Best Practices & Implementation Strategies

To comply with PC.02.03.01 and leverage evidence‑based strategies, hospitals should adopt the following best practices:

1. Standardized Education Assessment Tools

Use validated instruments such as the Newest Vital Sign or TOFHLA (Test of Functional Health Literacy in Adults) to gauge health literacy. Incorporate a standardized “Patient Education Assessment Form” into the admission workflow that captures:

• Preferred language and need for interpreter.

• Education level (e.g., “Reads at approximately 6th‑grade level”).

• Cognitive status (e.g., Mini‑Cog, MOCA for older adults).

• Sensory impairments (vision, hearing).

• Support system (e.g., primary caregiver, availability of home health).

2. Multidisciplinary Education Team

Establish a patient education council made up of:

• Nurses (including clinical nurse educators).

• Pharmacists (for MedRec and medication teaching).

• Case managers/social workers (for social determinants of health).

• Dietitians (for disease‑specific nutritional counseling).

• Therapists (PT/OT for functional training).

• Chaplains or cultural liaisons (for spiritual/cultural considerations).

This team collaborates to create disease‑specific education modules, standardized checklists, and printable handouts in multiple languages.

3. Teach‑Back & Return‑Demonstration Trainings

Provide hospital‑wide training on Teach‑Back and Return‑Demonstration techniques. Include:

• Role‑playing sessions where staff practice phrasing (“In your own words, tell me how you will measure your blood sugar at home”).

• Audit and feedback: Periodically review video‑recorded or observed patient encounters (with consent) and provide constructive feedback.

4. Health Literacy‑Friendly Materials

Ensure that all written materials meet Plain Language Guidelines (e.g., from AHRQ’s Health Literacy Universal Precautions Toolkit) [7]. Key tips:

• Use large fonts (14–16 pt).

• Break text into short paragraphs (no more than 2–3 sentences).

• Incorporate bullet points and pictorial aids.

• Engage professional medical translators for all commonly used materials (e.g., AVS, wound care instructions).

5. Structured Discharge Workflow

Implement a Discharge Huddle each morning that includes:

• Education Status Check: Has each patient received all mandatory education?

• MedRec Review: Is the final medication list reconciled and explained?

• AVS Generation: Is the after‑visit summary ready, with translated versions if needed?

• Follow‑Up Planning: Are appointments scheduled, and do patients know transportation arrangements?

Staff document completion of each item in a Discharge Checklist in the EHR. Uncompleted items trigger an escalation protocol (e.g., nurse educator assigned to finish).

6. Technology & Patient Portals

Use the hospital’s patient portal to:

• Host educational videos on topics like wound care or medication administration.

• Provide digital copies of after‑visit summaries that patients can print or review on smartphones.

• Allow secure messaging so patients can ask follow‑up questions to care teams within 48 hours of discharge, reducing readmissions.

7. Post‑Discharge Follow‑Up Calls

Within 48 hours of discharge, specially trained transitions-of-care nurses call patients to:

• Confirm they obtained medications.

• Verify they understand how and when to take them.

• Review any new symptoms.

• Confirm follow‑up appointment dates.

Calls are documented in the EHR under a “Transitions of Care” note template, and any concerns are escalated to the primary team or case manager.

7. How Evalucare (Evalucare.net) Evaluates Compliance with PC.02.03.01

When adverse events occur, especially those related to miscommunication or inadequate education, patients, families, and attorneys need a thorough, unbiased review of whether the hospital adhered to Joint Commission standards.

Evalucare (Evalucare.net) offers expert chart review services from quality and medical experts specifically tailored to questions of patient education and transitions of care. Here’s how Evalucare supports stakeholders:

For Families & Attorneys

1. Independent Retrospective Medical Care Review:

   • Evalucare’s clinical experts (experienced nurses, pharmacists, and physicians) examine the medical record for documented evidence of education and training:

     • Was the patient’s learning assessment completed? (EP 1)

     • Was there a written education plan? (EP 2)

     • What methods were used, and were they appropriate for the patient’s literacy/cognitive level? (EP 3)

     • Is there documented teach‑back or return‑demonstration? (EP 4)

     • Are discharge teaching notes, AVS, and MedRec documented? (EP 5)

     • Did education continue during transitions? (EP 6)

2. Benchmarking Against Industry Standards:

   • Evalucare compares the hospital’s practices to published best practices (e.g., AHRQ, NQF transitions measures) and Joint Commission directives to identify deviations.

3. Expert Reports & Testimony:

   • Detailed, structured reports outline compliance gaps

For Hospitals & Quality Leaders

1. Proactive Chart Audits & Root‑Cause Analysis:

   • Evalucare conducts periodic, randomized chart audits to assess PC.02.03.01 compliance. They use a standardized scoring rubric (0 = Not Met, 1 = Partially Met, 2 = Fully Met) for each EP.

   • They identify systemic issues—such as “100% of hip replacement patients lacked documented teach‑back for anticoagulation”—and provide prioritized recommendations (e.g., EHR modifications, staff trainings).

2. Customized Education Program Development:

   • Based on audit findings, Evalucare collaborates with hospital educators to develop tailored workshops, online modules, or toolkits.

   • Sample materials include diabetes self‑management booklets, heart failure “red flags” magnets, and multilingual wound‑care cards.

3. Ongoing Performance Dashboards:

   • Evalucare delivers quarterly dashboards showing compliance trends over time, benchmarked against peer hospitals.

   • Leaders can track progress: “EP 4 compliance rose from 45% in Q1 to 78% in Q3 after implementing teach‑back workshops.”

4. Regulatory & Accreditation Support:

   • Expert findings can be used in Joint Commission survey preparations (e.g., mock surveys focusing on patient education).

   • Evalucare helps craft policy updates to ensure all EPs are clearly operationalized (e.g., a standalone “Patient Education Policy: PC.02.03.01” that incorporates standardized forms and workflows).

     
     

8. Conclusion: Elevating Patient Education as a Safety Priority

Standard PC.02.03.01 compels hospitals to shift from a passive model, “Here are your discharge papers,” to an active, collaborative model: Assess learning needs, craft individualized education plans, teach using best practices, verify understanding, and reinforce lessons through transitions of care. When done well, patient education becomes a cornerstone of safe, reliable care, reducing medication errors, preventing avoidable readmissions, and enhancing patient satisfaction.

Yet, when education falls short, whether due to time constraints, poor documentation, or assumptions about patient literacy, the consequences can be dire. From warfarin overdoses to insulin‑induced seizures, the malpractice risk is real, and the human toll is unacceptable. Fortunately, tools like discharge summaries, after‑visit summaries, teach‑back, and medication reconciliation provide proven frameworks for success.

Finally, by partnering with expert reviewers like Evalucare (Evalucare.net), hospitals gain objective insight into their performance and know when to recalibrate efforts. For patients and families navigating the aftermath of an adverse event, Evalucare’s meticulous reviews can uncover whether communication standards, like PC.02.03.01—were honored or breached.

References and Links

1. Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.

• Landmark report establishing the link between communication failures and medical errors.

• Full Text

2. Jack BW, Chetty VK, Anthony D, et al. “A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial.” Ann Intern Med. 2009;150(3):178–187.

• Demonstrates that structured discharge education and post‑discharge phone calls reduce readmissions by 30%.

• Link

3. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. “The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital.” Ann Intern Med. 2003;138(3):161–167.

• Finds that 19% of patients experience adverse events within 3 weeks of discharge, half of which are preventable.

• Link

4. Joint Commission. Comprehensive Accreditation Manual for Hospitals (CAMH), Provision of Care, Chapter PC (Provision of Care).

• Official source for Standard PC.02.03.01; accessible to accredited organizations via JC Connect.

• Joint Commission Website

5. Agency for Healthcare Research and Quality (AHRQ). Health Literacy Universal Precautions Toolkit.

• A step‑by‑step guide to making health care easier for patients to understand.

• Link

6. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. “Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists.” J Hosp Med. 2007;2(5):314–323.

• Outlines best practices for discharge teaching, MedRec, and follow‑up.

• Link

7. Divine HR, Lin SY. “Interpreters and Medical Malpractice.” J Gen Intern Med. 2018;33(1):23–28.

• Reviews cases in which lack of qualified interpretation led to malpractice claims.

• Link

8. Muller S, Hasselrot J, Ekelund M, Bjorvell H. “Adverse Drug Events and Medication Incidents in Care of the Elderly.” J Clin Nurs. 2013;22(5–6):658–668.

• Links inadequate patient education to 30% of ADEs in geriatric populations.

• Link

9. O’Leary KJ, Liebovitz DM, Baker DW. “How Hospitalists Spend Their Time: Insights on Efficiency and Safety.” J Hosp Med. 2006;1(2):88–92.

• Examines time constraints on rounding and opportunities for structured teaching.

• Link

10. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. “Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety and Continuity of Care.” JAMA. 2007;297(8):831–841.- Highlights that 50% of discharge summaries do not reach primary care physicians promptly.

11. EvaluCare. “Patient Education & Transitions of Care Audit Module,” 2024 Edition.- Detailed internal reference for auditing PC.02.03.01 compliance.- Evalucare.net

About Evalucare:

Evalucare is a nationally recognized clinical review service specializing in retrospective chart audits, expert case reviews, and compliance benchmarking. Hospitals, health‑systems, attorneys, and patients trust Evalucare’s multidisciplinary team to assess whether Joint Commission standards, like PC.02.03.01, were met and how lapses may have contributed to patient harm. By combining evidence‑based criteria, proprietary audit tools, and seasoned clinicians, Evalucare provides clear, actionable insights to reduce risk, enhance patient safety, and improve outcomes.

Visit Evalucare.net to learn more.