RT Journal Article SR Electronic T1 Harms from discharge to primary care: mixed methods analysis of incident reports JF British Journal of General Practice JO Br J Gen Pract FD British Journal of General Practice SP e829 OP e837 DO 10.3399/bjgp15X687877 VO 65 IS 641 A1 Huw Williams A1 Adrian Edwards A1 Peter Hibbert A1 Philippa Rees A1 Huw Prosser Evans A1 Sukhmeet Panesar A1 Ben Carter A1 Gareth Parry A1 Meredith Makeham A1 Aled Jones A1 Anthony Avery A1 Aziz Sheikh A1 Liam Donaldson A1 Andrew Carson-Stevens YR 2015 UL http://bjgp.org/content/65/641/e829.abstract AB Background Discharge from hospital presents significant risks to patient safety, with up to one in five patients experiencing adverse events within 3 weeks of leaving hospital.Aim To 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 setting A mixed methods analysis of 598 patient safety incident reports in England and Wales related to ‘Discharge’ from the National Reporting and Learning System.Method Detailed 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.Results A 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.Conclusion Significant harm was evident due to deficits in the discharge process. Interventions in this area need to be evaluated and learning shared widely.