Evidence map›Paper›PMID 26622036›Full record

ReviewThe British journal of general practice : the journal of the Royal College of General Practitioners2015

Harms from discharge to primary care: mixed methods analysis of incident reports.

Huw Williams, Adrian Edwards, Peter Hibbert, Philippa Rees, Huw Prosser Evans, Sukhmeet Panesar, Ben Carter, Gareth Parry, Meredith Makeham, Aled Jones and 4 more

Open access · hybridAbstract readReview
PubMed Full text at PMC Publisher
In one paragraph

Review in The British journal of general practice : the journal of the Royal College of General Practitioners, 2015. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 49 papers, 1 of them a synthesis that pooled it.

0numbers the graph read from it
0cells of the map it votes in
49citing papers in PubMed, 1 pooled it
5.9field-weighted citation impact, top 3% of its field
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

49 citing papers in PubMed, 1 synthesis or guideline pooled it, 79 citations in OpenAlex.

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  18. A qualitative formative evaluation of a patient facing intervention to improve care transitions for older people moving from hospital to home.Health expectations : an international journal of public participation in health care and health policy · 2022
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  19. A mixed-methods characterisation of patient safety incidents by primary eye care practitioners.Ophthalmic & physiological optics : the journal of the British College of Ophthalmic Opticians (Optometrists) · 2022
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4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

14 authors at 6 institutions in 3 countries.

Huw WilliamsPrimary Care Patient Safety Research Group, Cochrane Institute of Primary Care and Public Health; School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK.
Adrian EdwardsPrimary Care Patient Safety Research Group, Cochrane Institute of Primary Care and Public Health; School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK.
Peter HibbertAustralian Institute of Health Innovation, University of New South Wales, Sydney, Australia.
Philippa ReesPrimary Care Patient Safety Research Group, Cochrane Institute of Primary Care and Public Health; School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK.
Huw Prosser EvansPrimary Care Patient Safety Research Group, Cochrane Institute of Primary Care and Public Health; School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK.
Sukhmeet PanesarCentre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
Ben CarterPrimary Care Patient Safety Research Group, Cochrane Institute of Primary Care and Public Health; School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK.
Gareth ParryInstitute for Healthcare Improvement, Cambridge, MA, US; assistant professor, Department of Paediatrics, Harvard Medical School, Boston, MA, US.
Meredith MakehamAustralian Institute for Health Innovation, Centre for Health Systems and Safety Research, Macquarie University, North Ryde, Australia.
Aled JonesSchool of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK.
Anthony AveryFaculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK.
Aziz SheikhCentre 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.
Liam DonaldsonDepartment of Surgery and Cancer, Imperial College London, London, UK.
Andrew Carson-StevensPrimary 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.
Cardiff University · GBUniversity of Edinburgh · GBImperial College London · GBInstitute for Healthcare Improvement · USUniversity of Nottingham · GBUNSW Sydney · AU

Funding

Department of Health 12/64/118
6 · The paper itself

Abstract

backgroundDischarge from hospital presents significant risks to patient safety, with up to one in five patients experiencing adverse events within 3 weeks of leaving hospital.

aimTo 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. DESIGN AND

settingA mixed methods analysis of 598 patient safety incident reports in England and Wales related to 'Discharge' from the National Reporting and Learning System.

methodDetailed 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.

resultsA 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.

conclusionSignificant harm was evident due to deficits in the discharge process. Interventions in this area need to be evaluated and learning shared widely.

Indexed as

Patient DischargePrimary Health CareState MedicineEnglandHumansMedical ErrorsPatient SafetyQualitative ResearchReferral and ConsultationRisk ManagementSafety ManagementWalesadverse eventsdischargeharmpatient safetyprimary caresafety incident reports

Identifiers

PMID26622036
PMCPMC4655737
OpenAlexW2187371925

What OpenQuestion holds

Textmetadata
LicenceCC BY
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.