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Watchdog calls for audit of hospital discharge summaries

By Nigel Praities

The National Patient Safety Agency is urging trusts to urgently review hospital discharge information, after an audit uncovered a string of horror stories about the quality of information being passed to GPs.

The NHS safety watchdog said badly written, inaccurate discharge summaries and poor communication is putting patients lives at risk, and recommends hospital managers urgently audit their discharge systems to make them quicker and safer.

The warning comes amid rising concern over information hospitals provide to GPs, with an LMC motion this year recognising increasing ‘critical incidents and disasters' caused by a lack of information provided to GPs at hospital discharge.

A Pulse investigation in May revealed more than a third of trusts had received complaints from GPs over their discharge policies in the past year, and that some practices were waiting four weeks for discharge summaries to come through.

The NPSA reviewed all 72,000 patient safety reports from the National Reporting and Learning Service in 2007 and found 14% occurred in primary care.

A third of these incidents were medication-related and were common in the ‘interface' between primary and secondary care, according to the watchdog.

‘Particular problems appear to be related to faxed prescriptions and discharge summaries, although this may just be because these are common means of communication.

‘[PCOs should] review processes for the accurate and timely transfer of medication-related information across all interfaces, but in particular in conjunction with the acute sector,' the report recommends.

Professor David Cousins, head of safer medication at the NPSA said: ‘We suggest all NHS organisations review their systems for communication about medicines, and promote safer systems and the use of new technology in the commissioning process.

‘This should include reviewing the quality of the data to ensure these communication systems work effectively.

Dr John Canning, a GPC member and LMC secretary for Cleveland, said late and illegible discharge summaries were a major problem that could be easily solved.

‘We regularly get signage notes saying they recommend a certain treatment and they are not always eligible and more importantly, when they are scanned in they are very difficult to understand.

‘Technology can help. An example is that drug results come to us in a timely, legible and allocated to a named patient – we don't seem to have any where near the same system for other written communications,' he said.

Discharge summary horror stories

- Hospital letter with two typing errors faxed to GP surgery. After an enquiry raised by patient's GP, oral steroid dose found to be 15 mg and not 50 mg, and methotrexate should have been taken weekly rather than daily

- Patient received 25 units of insulin in hospital to control diabetes. Discharge referral resulted in patient receiving 90 units of insulin at home. Patients' family raised alarm over low blood glucose levels

- Following a patient death due to poor warfarin monitoring one practice decided to take over INR testing but the trust failed to point out one blind, housebound patient also needed methotrexate monitoring

Source: Safety in doses: improving the use of medicines in the NHS. NPSA report 2009. Available at

The NPSA has called for hospitals to urgently review discharge information The NPSA has called for hospitals to urgently review discharge information

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