title: Harms from discharge to primary care: mixed methods analysis of incident reports.
abstract: BACKGROUND
  Discharge from hospital presents significant risks to patient safety, with up to one in five patients experiencing adverse events within 3 weeks of leaving hospital.
  
  
  OBJECTIVE
  To describe the frequency and types of patient safety incidents associated with discharge from secondary to primary care, and commonly described contributory factors to identify recommendations for practice.
  
  
  METHODS
  A mixed methods analysis of 598 patient safety incident reports in England and Wales related to 'Discharge' from the National Reporting and Learning System.
  
  
  METHODS
  Detailed data coding (with 20% double-coding), data summaries generated using descriptive statistical analysis, and thematic analysis of special-case sample of reports. Incident type, contributory factors, type, and level of harm were described, informing recommendations for future practice.
  
  
  RESULTS
  A total of 598 eligible reports were analysed. The four main themes were: errors in discharge communication (n = 151; 54% causing harm); errors in referrals to community care (n = 136; 73% causing harm); errors in medication (n = 97; 87% causing harm); and lack of provision of care adjuncts such as dressings (n = 62; 94% causing harm). Common contributory factors were staff factors (not following referral protocols); and organisational factors (lack of clear guidelines or inefficient processes). Improvement opportunities include developing and testing electronic discharge methods with agreed minimum information requirements and unified referrals systems to community care providers; and promoting a safety culture with 'safe discharge' checklists, discharge coordinators, and family involvement.
  
  
  CONCLUSIONS
  Significant harm was evident due to deficits in the discharge process. Interventions in this area need to be evaluated and learning shared widely.
authors.affiliation: Primary Care Patient Safety Research Group, Cochrane Institute of Primary Care and Public Health; School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK.
authors.forename: Huw
authors.initials: H
authors.lastname: Williams
authors.affiliation: Primary Care Patient Safety Research Group, Cochrane Institute of Primary Care and Public Health; School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK.
authors.forename: Adrian
authors.initials: A
authors.lastname: Edwards
authors.affiliation: Australian Institute of Health Innovation, University of New South Wales, Sydney, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Hibbert
authors.affiliation: Primary Care Patient Safety Research Group, Cochrane Institute of Primary Care and Public Health; School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK.
authors.forename: Philippa
authors.initials: P
authors.lastname: Rees
authors.affiliation: Primary Care Patient Safety Research Group, Cochrane Institute of Primary Care and Public Health; School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK.
authors.forename: Huw
authors.initials: H
authors.lastname: Prosser Evans
authors.affiliation: Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
authors.forename: Sukhmeet
authors.initials: S
authors.lastname: Panesar
authors.affiliation: Primary Care Patient Safety Research Group, Cochrane Institute of Primary Care and Public Health; School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK.
authors.forename: Ben
authors.initials: B
authors.lastname: Carter
authors.affiliation: Institute for Healthcare Improvement, Cambridge, MA, US; assistant professor, Department of Paediatrics, Harvard Medical School, Boston, MA, US.
authors.forename: Gareth
authors.initials: G
authors.lastname: Parry
authors.affiliation: Australian Institute for Health Innovation, Centre for Health Systems and Safety Research, Macquarie University, North Ryde, Australia.
authors.forename: Meredith
authors.initials: M
authors.lastname: Makeham
authors.affiliation: School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK.
authors.forename: Aled
authors.initials: A
authors.lastname: Jones
authors.affiliation: Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK.
authors.forename: Anthony
authors.initials: A
authors.lastname: Avery
authors.affiliation: Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK; visiting professor of medicine, Harvard Medical School, Boston, MA, US.
authors.forename: Aziz
authors.initials: A
authors.lastname: Sheikh
authors.affiliation: Department of Surgery and Cancer, Imperial College London, London, UK.
authors.forename: Liam
authors.initials: L
authors.lastname: Donaldson
authors.affiliation: Primary Care Patient Safety Research Group, Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK; patient safety research lead, Primary and Emergency Care Research Centre Wales; visiting chair of healthcare improvement, Department of Family Practice, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Andrew
authors.initials: A
authors.lastname: Carson-Stevens
mesh_terms: D004739:England / Q000453:epidemiology; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D010351:Patient Discharge; D061214:Patient Safety; D011320:Primary Health Care; D036301:Qualitative Research; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012308:Risk Management; D017751:Safety Management; D013222:State Medicine; D014852:Wales / Q000453:epidemiology
keywords: adverse events; discharge; harm; patient safety; primary care; safety incident reports