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Accuracy of e-discharge summaries

Our audit revealed numerous errors in electronic summaries. By Edwin Hian Ong and Dr Anita Sharma

Studies have shown that junior doctors are more prone to make errors in discharge summaries (Photograph: Corbis)
Studies have shown that junior doctors are more prone to make errors in discharge summaries (Photograph: Corbis)

The hospital discharge summary contains valuable information about the patient during their stay in hospital. This is crucial in relation to the continuity of care provided after the patient is discharged back to their GP.

My practice recently carried out an audit of the accuracy of electronic discharge summaries (e-summaries).

Conventionally, hospital discharge summaries have been either handwritten or dictated. This often results in wrong or missing information in the report. At the primary/secondary care interface, there is also a risk of poly-pharmacy.

When there are a number of clinicians treating the same patient, they may prescribe contraindicated medications without realising.

Often, junior doctors do the discharge summaries and studies have shown that they are more prone to make mistakes.1

Transfer of information
The transfer of information between primary and secondary care has undoubtedly been a longstanding problem in medicine. Hospitals often complain that there is inadequate background information from the GP regarding patients' medical and drug histories.

On the other hand, GPs argue that hospitals do not convey enough data about what happened to their patients when they were in the hospital.

To investigate this further, an audit was carried out to evaluate the quality of information recorded in e-summaries, and determine if improvements could be made to the format of the forms.

Data were collected from four GP practices. In total, 40 patients were included.

The findings showed that a significant number of the e-summaries contained at least one or more sections of missing information.

Only 30 discharge forms clearly stated the diagnosis at discharge, while nearly all did not document whether the patient had allergies.

Only four of the e-summaries were received by the GP within 48 hours of the patient leaving the hospital. Only 10 patients had their regular medications documented. The figure is only slightly better in relation to new medications initiated during admission, with this being recorded in around a third of cases.

IN SUMMARY
  • Audit of 40 e-summaries of patient discharge information showed a high level of errors.
  • Only four e-summaries reached the patients' GPs within 48 hours of hospital discharge.
  • Only 30 e-summaries clearly stated the diagnosis at discharge.
  • Regular medications were documented for only 10 patients and only two stated patients were discharged with seven days' supply.
  • Medication initiated while admitted was only documented for about a third of patients.
  • With nearly all, the section for GP action was very poorly completed.

Clinical data
Only two e-summaries documented that the patients had received a seven-day supply of their regular medications. However, a section that did meet expectations was that of the discharging consultant's name: this was stated on all the forms.

With clinical data during the hospital stay, some sections were well documented while others were not. Importantly, the section for GP action following discharge was very poorly recorded, with only 15% containing information.

Of the 40 e-summaries, none had entries in the sections for patient's weight, MRSA status, smoking cessation advice (whether given) and venous thromboembolism, while only one gave the patient's discharge destination (to own residence/residential/nursing home/relative's house).

The cynical might ask why some of the sections are on the e-summary at all if they are never or hardly ever completed. Further audit is required to identify the exact reasons for the incompleteness of the e-summaries.

However, our sample size was small, the data were collected over a short period, only one hospital was involved and a small number of doctors filled in the e-summaries.

Nonetheless, the results suggest that improvements are definitely needed to conform to the Quality, Innovation, Productivity and Prevention (QIPP) programme for delivering quality efficiently (see QIPP resources at www.improvement.nhs.uk). For a more accurate representation, a larger scale of audit needs to be performed on a hospital trust-wide level, including surgery, A&E, paediatrics and other specialties.

Are GPs properly trained?
In our audit, the doctors responsible for the patient's discharge may be the major cause of the large number of medication errors and information omissions.

If so, are doctors (at all levels) properly trained to complete e-summaries? The format of the e-summary may also need to be scrutinised and redesigned to make it more user-friendly so that data can be entered efficiently.

Hopefully, more sophisticated e-summary systems, which automatically update data into the various sections, may be introduced in future.

For example, studies have shown that Patient Tracker (www.patient-tracker.com), a software application used in the US, is effective in facilitating the discharge process.

  • Dr Sharma is a GP in Oldham, Greater Manchester.
  • The audit was carried out by Edwin Hian Ong, a fourth year medical student at University of Manchester Medical School, during the SSC module at Dr Sharma's practice.

CPD IMPACT: EARN MORE CREDITS

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Discuss with the practice team setting up an audit project to test how accurate discharge summaries (electronic/non-electronic) are in your area.
  • Ask local practices to join in by making their patients' discharge summaries available.
  • Carry out the audit and feed back results to the hospital(s) concerned.

Save this article and add notes with your free online CPD organiser at gponline.com/cpd

Take clinical tests and claim certificates for CPD at myCME.com/gp

Reference
1. Callen J, McIntosh J, Li J. Int J Med Inform 2010; 79(1): 58-64.

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