Problems surrounding the adequate and timely communication of essential information to primary and social care at the time a patient is discharged from hospital has been identified as a particular risk to patient safety. Between October 2012 and September 2013, out of the 10,000 incidents relating to discharge reported to the National Reporting and Learning System, approximately 33% of these incidents were associated with issues around communication.
These incidents included:
- information about required follow up diagnostic tests not being passed to GPs resulting in them being missed;
- quality of discharge information or failure to receive a discharge letter; and
- failure to refer to primary care or community services, e.g. district nursing.
To help prevent these types of incident, NHS England is leading a national programme of work to support organisations in improving the communication and management of information, building on successful local and national initiatives already in place.
The programme is run in partnership with the regional Patient Safety Collaboratives and Academic Health Science Networks.
Patient Safety Alert
In August 2014 NHS England issued a Patient Safety Alert asking health and social care organisations to complete a questionnaire to help form a national picture about barriers to safe discharge. They were also asked to share examples of initiatives and practices that have helped to improve communication on discharge, resulting in the case studies below.
Standards for the communication of patient diagnostic test results on discharge from hospital
NHS England has developed a set of standards for the communication of patient diagnostic test results when they are discharged from hospital. The standards, endorsed by the Academy of Royal Colleges, describe acceptable safe practice around how diagnostic test results should be communicated between secondary and primary and social care and also with patients. This is part of a wider national patient safety programme around discharge to protect patients from potential harm caused by delays or errors in the communication of information between care providers.
A number of the examples of good practice received following the Patient Safety Alert have now been translated into individual case studies. These case studies are not systematic reviews or evidence based examples of best practice. Instead, they are a presentation of improvement projects that may support other organisations wishing to address similar topics.
You can access the case studies by clicking on the links below, which represent the seven common themes identified through the analysis of the questionnaires returned following the alert and best practice literature. We have also sorted these case studies by AHSN area to help you find local examples and will continue to add new case studies as they become available.
Each case study remains the property of the providing organisation and is independent to NHS England.
Case studies by topic
- Discharge liaison service
- Electronic systems and records
- Medicines reconciliation
- Policies and systems that link health and social care
- Systems that involve patients in their care
- Systems that ensure provision of high quality information
- Systems to ensure information is acted on after discharge
Case studies by AHSN
These case studies have also been sorted by the AHSN areas below. We will continue to add new case studies as they become available so please remember to check back for updates. This will include case studies from the AHSN areas not currently listed.
- East Midlands
- Imperial College Health Partners
- Greater Manchester
- North East & North Cumbria
- North West Coast
- West Midlands
- Yorkshire & Humber
As well as the case studies we have also compiled a resource library to further support organisations to improve communication between health and social care providers when a patient is discharged from hospital. The resource library contains a range of webinars, guidance, academic papers and reports.