01.09.14
NHS England issues patient safety alert on poor discharge communication
NHS England has issued a patient safety alert after it was revealed that a ‘breakdown’ in communication at the point someone is discharged from hospital to primary care could leave them at “risk of harm”.
It says communication at handover is identified as a particular area of risk and accounted for approximately 33% of 10,000 incidents reported to the National Reporting and Learning Service (NRLS) between October 2012 and September 2013.
Following a review of this information, it was revealed that some patients are discharged without “adequate” and “timely” information at the point of handover to teams in primary and social care.
“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,” said NHS England.
It is now asking NHS organisations for information, as part of Stage 1 Alert, 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.
Information received through the patient safety alert questionnaires and best practice template will then be used to inform a subsequent Stage 2 Alert (Resource), which will provide a range of resources and recommendations to support organisations in improving safety of handover at discharge at a local level.
All NHS organisations have been asked to contribute to this alert by 13 October 2014. For more information, click here.
Patient safety alerts are part of NHS England’s work to rapidly alert the healthcare system to risks and provide guidance on preventing potential incidents that may lead to harm or death. The alerts are issued via the Central Alerting System (CAS), a web-based cascading system for issuing alerts.
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