Reaching the summit of discharge summaries: a quality improvement project.

Richard Thomas Richmond; Isobel Joy McFadzean; Pramodh Vallabhaneni

Study

Reaching the summit of discharge summaries: a quality improvement project.

March 3, 2021

Richmond RT, McFadzean IJ, Vallabhaneni P. BMJ Open Qual. 2021;10(1):e001142.

View more articles from the same authors.

Timely completion of discharge summaries can improve handoffs with outpatient physicians and ensure communication of potential patient safety problems. This quality improvement project used an established change model to improve the rate of discharge summary completed within 24 hours from less than 10%, to 84% within 2 months.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care.

March 17, 2021

The standardisation of handoffs in a large academic paediatric emergency department using I-PASS.

July 28, 2021

Therapeutic duplication on the general surgical wards.

October 13, 2021

Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme.

January 19, 2022

Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project.

December 22, 2021

Patient and caregiver factors in ambulatory incident reports: a mixed-methods analysis.

November 24, 2021

Systems engineering analysis of diagnostic referral closed-loop processes.

March 9, 2022

Unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal MRI in UK primary care.

August 11, 2021

Assessing quality of older persons' emergency transitions between long-term and acute care settings: a proof-of-concept study.

May 18, 2022

Promoting patient and nurse safety: testing a behavioural health intervention in a learning healthcare system: results of the DEMEANOR pragmatic, cluster, cross-over trial.

March 2, 2022

Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool.

March 18, 2020

Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study.

February 24, 2021

National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020.

March 1, 2023

Is anybody 'Learning' from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017-2020.

February 22, 2023

Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly.

September 30, 2020

Prioritising recommendations following analyses of adverse events in healthcare: a systematic review.

November 4, 2020

Impact of full personal protective equipment on alertness of healthcare workers: a prospective study.

February 2, 2022

Using human factors and ergonomics principles to prevent inpatient falls.

April 20, 2022

Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey.

February 12, 2020

Defining avoidable healthcare-associated harm in prisons: a mixed-method development study.

April 19, 2023

Measuring psychological safety and local learning to enable high reliability organisational change.

November 9, 2022

The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study.

August 24, 2022

Predictors and outcomes of patient safety culture: a cross-sectional comparative study.

July 27, 2022

Instruments for measuring patient safety competencies in nursing: a scoping review.

June 15, 2022

Indicators for implementation outcome monitoring of reporting and learning systems in hospitals: an underestimated need for patient safety.

May 4, 2022

Improving critical incident reporting in primary care through education and involvement.

October 16, 2019

Severe illness getting noticed sooner - SIGNS-for-Kids: developing an illness recognition tool to connect home and hospital.

January 15, 2020

Making communication and resolution programmes mission critical in healthcare organisations.

November 11, 2020

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Less is more: a project to reduce the number of PIMs (potentially inappropriate medications) on an elderly care ward.

May 18, 2016

Healthcare professionals' perception of safety culture and the Operating Room (OR) Black Box technology before clinical implementation: a cross-sectional survey.

March 22, 2023

Sustaining improvement of hospital-wide initiative for patient safety and quality: a systematic scoping review.

February 1, 2023

Support for healthcare workers and patients after medical error through mutual healing: another step towards patient safety.

January 18, 2023

Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study.

September 16, 2020

Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study.

December 23, 2020

Managing teamwork in the face of pandemic: evidence-based tips.

June 24, 2020

Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients.

August 26, 2020

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy.

November 25, 2020

Core competencies for patient safety research: a cornerstone for global capacity strengthening.

February 2, 2011

Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs.

March 10, 2021

Effects of CPOE-based medication ordering on outcomes: an overview of systematic reviews.

July 8, 2020

Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices.

June 30, 2021

A realist synthesis of pharmacist-conducted medication reviews in primary care after leaving hospital: what works for whom and why?

December 2, 2020

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

May 19, 2021

Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report.

January 16, 2013

Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents.

March 22, 2023

Patient feedback for safety improvement in primary care: results from a feasibility study.

July 29, 2020

Developing open disclosure strategies to medical error using simulation in final-year medical students: linking mindset and experiential learning to lifelong reflective practice.

March 31, 2021

Patients' perceptions of safety in emergency medical services: an interview study.

December 2, 2020

Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study.

January 8, 2020

Suicide as an incident of severe patient harm: a retrospective cohort study of investigations after suicide in Swedish healthcare in a 13-year perspective.

March 31, 2021

Incidence, duration and risk factors associated with delayed and missed diagnostic opportunities related to tuberculosis: a population-based longitudinal study.

March 24, 2021

'It's all about patient safety': an ethnographic study of how pharmacy staff construct medicines safety in the context of polypharmacy.

March 10, 2021

Safe clinical practice for patients hospitalised in mental health wards during a suicidal crisis: qualitative study of patient experiences.

December 23, 2020

NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme.

July 21, 2021

Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a scoping review.

June 30, 2021

Safe opioid prescribing: a prognostic machine learning approach to predicting 30-day risk after an opioid dispensation in Alberta, Canada.

June 16, 2021

Measuring safety in older adult care homes: a scoping review of the international literature.

May 19, 2021

Responses of physicians to an objective safety and quality knowledge test: a cross-sectional study.

October 6, 2021

Exploring the factors that promote or diminish a psychologically safe environment: a qualitative interview study with critical care staff.

September 22, 2021

Effects of interorganisational information technology networks on patient safety: a realist synthesis.

December 9, 2020

Higher incidence of adverse events in isolated patients compared with non-isolated patients: a cohort study.

November 18, 2020

Dimensions of safety culture: a systematic review of quantitative, qualitative and mixed methods for assessing safety culture in hospitals.

September 1, 2021

Towards safer healthcare: qualitative insights from a process view of organisational learning from failure.

August 25, 2021

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg.

June 15, 2022

Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study.

January 9, 2019

'Care left undone' during nursing shifts: associations with workload and perceived quality of care.

August 14, 2013

Exploration of prescribing error reporting across primary care: a qualitative study.

April 13, 2022

Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey.

February 16, 2022

Research to improve diagnosis: time to study the real world.

January 26, 2022

Application of electronic trigger tools to identify targets for improving diagnostic safety.

October 17, 2018

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

May 10, 2017

February 2, 2022

Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD).

September 15, 2021

Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses and inpatient units.

September 23, 2020

Chronic hospital nurse understaffing meets COVID-19: an observational study.

September 9, 2020

August 19, 2020

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study.

July 29, 2020

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.

December 16, 2020

Factors influencing physician responsiveness to nurse-initiated communication: a qualitative study.

December 2, 2020

Vulnerability of the medical product supply chain: the wake-up call of COVID-19.

November 25, 2020

Inpatient patient safety events in vulnerable populations: a retrospective cohort study.

November 18, 2020

SEIPS 2.0: a human factors framework for studying and improving the work of healthcare professionals and patients.

October 3, 2013

Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study.

October 7, 2020

Adverse events present on arrival to the emergency department: the ED as a dual safety net.

March 11, 2020

Changing hospital organisational culture for improved patient outcomes: developing and implementing the Leadership Saves Lives intervention.

August 12, 2020

Identifying and encouraging high-quality healthcare: an analysis of the content and aims of patient letters of compliment.

August 5, 2020

The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and improve safety.

May 5, 2021

Time out! Rethinking surgical safety: more than just a checklist.

April 28, 2021

Timeout procedure in paediatric surgery: effective tool or lip service? A randomised prospective observational study.

March 24, 2021

Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial.

March 17, 2021

Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.

March 3, 2021

Moving beyond the weekend effect: how can we best target interventions to improve patient care?

June 30, 2021

Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes.

June 30, 2021

Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings.

October 6, 2021

Fall prevention implementation strategies in use at 60 United States hospitals: a descriptive study.

December 9, 2020

Out of sight, out of mind: a prospective observational study to estimate the duration of the Hawthorne effect on hand hygiene events.

November 11, 2020

Tiered daily huddles: the power of teamwork in managing large healthcare organisations.

October 7, 2020

Interventions targeted at reducing diagnostic error: systematic review.

September 8, 2021

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

On Patient Safety.

January 13, 2024

Challenge Competition: Impact of Patient Safety Tools.

December 12, 2023

A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings.

October 4, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada.

June 28, 2023

WebM&M Cases

Critical Echocardiogram Result Lost to Follow-up.

June 14, 2023

Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study.

June 7, 2023

Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.

May 31, 2023

Danger in discharge summaries: abbreviations create confusion for both author and recipient.

May 31, 2023

Just a Cup of Tea – an Introduction to the SEIPS Framework.

May 24, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

A decade after Francis: is the NHS safer and more open?

April 5, 2023

Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia.

March 8, 2023

NHS staff cried in safety interviews, says watchdog.

March 8, 2023

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

January 11, 2023

Electronic prescribing systems in hospitals to improve medication safety: a multi-methods research programme.

December 21, 2022

Discontinuation of outpatient medications: implications for electronic messaging to pharmacies using CancelRx.

December 7, 2022

Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.

November 16, 2022

Journal Article

Study

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

November 16, 2022

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

November 9, 2022

The effect of a system-level tiered huddle system on reporting patient safety events: an interrupted time series analysis.

October 12, 2022

Solutions from Professional Regulation and Beyond.

October 5, 2022

WebM&M Cases

Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.

September 28, 2022

Charlie Bourg was on the lookout for veterans harmed by a new VA computer system. He didn’t expect to be one of them.

September 21, 2022

The Psychological Safety Scale of the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey: a brief, diagnostic, and actionable metric for the ability to speak up in healthcare settings.

September 14, 2022

Healthcare Safety Investigations Conference 2022.

August 3, 2022

Wellbeing, burnout, and safe practice among healthcare professionals: predictive influences of mindfulness, values, and self-compassion.

June 8, 2022

Patient harm and institutional avoidability of out-of-hours discharge from intensive care: an analysis using mixed methods.

March 23, 2022

Factors associated with potentially missed acute deterioration in primary care: cohort study of UK general practices.

October 20, 2021

See More About The Topic

Hospitals

Ambulatory Clinic or Office

Quality and Safety Professionals

Medicine

Discontinuities, Gaps, and Hand-Off Problems

Reaching the summit of discharge summaries: a quality improvement project.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Reaching the summit of discharge summaries: a quality improvement project.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Clinician collaboration to improve clinical decision support: the Clickbusters initiative.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site