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NHS issues warning on poor discharge communication

Communication at handover accounted for a third of 10,000 incidents reported last year

Mark Gould

Monday, 01 September 2014

NHS England has issued a patient safety alert to help drive up the quality and timeliness of communication with primary and social care when patients are discharged from hospital.

It says communication at handover is identified as a particular area of risk and accounted for approximately 33% of the 10,000 incidents reported to the National Reporting and Learning Service (NRLS) between October 2012 and September 2013.

Review of these incidents identified that patients are sometimes discharged without adequate and timely communication of essential information at point of handover to all relevant staff and teams in primary and social care, including out-of-hours, and that information is not always acted on in a timely manner. "This can result in avoidable death and serious harm to patients due to a failure in continuity of care as well as avoidable readmission to secondary care," NHS England says.

It gives the example of a Continuing Care Team (CCT) which received a hospital discharge fax to provide daily wound care for a patient who was being discharged after a long inpatient stay with a right groin biopsy wound. However there was no mention on the fax that the patient was being discharged after a long inpatient stay with end stage fibrocystic lung disease and needed to receive end of life care. There was very poor communication from the ward and medical team to the GP and CCT at the time of discharge and no end of life drugs, DNRCPR or referral for community end of life care.

NHS England is leading a national programme of work to support organisations in improving the communication and management of information at handover by building on successful local and national initiatives already in place.

NHS England is asking organisations for information about their current local practices and challenges that will help form a national picture around handover at discharge. They are also being asked to provide examples of successful local initiatives designed to improve their discharge handover processes.

In addition, other groups including GPs, community nurses, social care, voluntary sector and medicines reconciliation are being asked to share their views on how the process can be improved. To collect the required information local sector specific questionnaires and a best practice template have been developed. This information will be used to develop a range of resources and recommendations to help healthcare providers to improve patient safety around handover at a local level.

Information received through the questionnaires and best practice template will be used to inform a subsequent Stage 2 Alert which will provide a range of resources and recommendations to support organisations in improving safety of handover at discharge at a local level. NHS England will also build a web-based best practice resource and is collaborating with local and national experts and enthusiasts in the field to provide series of webinars to facilitate system wide learning on this subject.

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