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Processing of discharge summaries in general practice : a retrospective record review
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Spencer, Rachel A., Spencer, Simon E. F., Rodgers, Sarah, Campbell, Stephen and Avery, Anthony (2018) Processing of discharge summaries in general practice : a retrospective record review. British Journal of General Practice, 68 (673). e576-e585. doi:10.3399/bjgp18X697877
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Official URL: http://doi.org/10.3399/bjgp18X697877
Abstract
Background
There is a need for greater understanding of the epidemiology of primary care patient safety in order to generate solutions to prevent future harm.
Aim
To estimate the rate of failures in processing actions requested in hospital discharge summaries, and to determine factors associated with these failures.
Design and setting
The authors undertook a retrospective records review. The study population was emergency admissions for patients aged ≥75 years, drawn from 10 practices in three areas of England.
Method
One GP researcher reviewed the records for 300 patients after hospital discharge to determine the rate of compliance with actions requested in the discharge summary, and to estimate the rate of associated harm from non-compliance. In cases where GPs documented decision-making contrary to what was requested, these instances did not constitute failures. Data were also collected on time taken to process discharge communications.
Results
There were failures in processing actions requested in 46% (112/246) of discharge summaries (95% confidence interval [CI] = 39 to 52%). Medications changes were not made in 17% (124/750) of requests (95% CI = 14 to 19%). Tests were not completed for 26% of requests (95% CI = 16 to 35%), and 27% of requested follow-ups were not arranged (95% CI = 20 to 33%). The harm rate associated with these failures was 8%. Increased risk of failure to process test requests was significantly associated with the type of clinical IT system, and male patients.
Conclusion
Failures occurred in the processing of requested actions in almost half of all discharge summaries, and with all types of action requested. Associated harms were uncommon and most were of moderate severity.
| Item Type: | Journal Article | |||||||||
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| Subjects: | R Medicine > RA Public aspects of medicine | |||||||||
| Divisions: | Faculty of Science > Statistics | |||||||||
| Library of Congress Subject Headings (LCSH): | Hospitals -- Admission and discharge -- Case studies, Primary care (Medicine), Physicians (General practice) | |||||||||
| Journal or Publication Title: | British Journal of General Practice | |||||||||
| Publisher: | Royal College of General Practitioners | |||||||||
| ISSN: | 0960-1643 | |||||||||
| Official Date: | August 2018 | |||||||||
| Dates: |
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| Volume: | 68 | |||||||||
| Number: | 673 | |||||||||
| Page Range: | e576-e585 | |||||||||
| DOI: | 10.3399/bjgp18X697877 | |||||||||
| Status: | Peer Reviewed | |||||||||
| Publication Status: | Published | |||||||||
| Access rights to Published version: | Open Access | |||||||||
| RIOXX Funder/Project Grant: |
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