Summary
NHS England has issued a patient safety alert in the effort to improve the quality and timeliness of communication with primary and social care when patients are discharged from hospital.
The alert invites organisations to supply feedback on current practice and challenges; and to share examples of potential improvements.
Reference
Risks arising from breakdown and failure to act on communication during handover at the time of discharge from secondary care. Patient Safety Alert Reference Number: NHS/PSA/W/2014/014. London: NHS England, August 29th 2014. Publications Gateway Reference 02167.
This relates to:
Reference
Review of National Reporting and Learning System (NRLS) incident data relating to discharge from acute and mental health trusts. London: NHS England, August 27th 2014.
Patient-Safety-Related Hospital Deaths in England: The Broader Picture
Deaths due to unsafe care in hospitals (i.e. pre-discharge) capable of being addressed by quality improvement in policies, procedures, and practices; grouped into six areas of apparent systemic failure:
- Mismanagement of deterioration (35%).
- Failure of prevention (26%).
- Deficient checking and oversight (11%).
- Dysfunctional patient flow (10%).
- Equipment-related errors (6%).
- Other (12%).
The most common incident types are failure to recognise deterioration (23%), inpatient falls (10%), healthcare-associated infections (10%), unexpected per-operative death (6%), and poor or inadequate handover (5%).
Reference
Donaldson, LJ. Panesar, SS. [and] Darzi, A. (2014). Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010-2012. PLoS Medicine, June 24th 2014, Vol.11(6), pp.e1001667. (Click here to view the PubMed abstract).
