Prospective audit of discharge summary errors

Abstract

During an 8-month interval of prospective audit, 63 of 637 (10 per cent) vascular discharge summaries were found to contain 94 errors. These comprised 11 (12 per cent) general errors, 21 (22 per cent) diagnostic errors, 19 (20 per cent) operative data errors, 19 (20 per cent) cases of incorrect clinical text information, 14 (15 per cent) missed complications and 10 (11 per cent) concerning follow-up arrangements. Overall, 2 per cent of consultant discharge summaries contained errors compared with 7 per cent for the senior registrar, 10 per cent for registrars and 17 per cent for senior house officers. Given that the majority of discharge summaries are currently prepared by junior staff, this study suggests that verification of the accuracy of clinical and management data should be an essential component of departmental audit meetings.

Electronic Versus Dictated Hospital Discharge Summaries: a Randomized Controlled Trial

“…5 There may also be deficiencies in discharge summary content [5][6][7][8] and accuracy. 5,9 Community-based physicians have attributed more than onethird of post-discharge adverse events to poor transfer of information. 10 Earlier work suggests that compared to conventional discharge summaries, electronically created discharge summaries have a greater likelihood of being generated, are more accurate, are delivered faster than dictated summaries, and are preferred by community physicians.…”

The ‘top 10’ urological procedures: a study of hospital episodes statistics 1998–99

“…in the operating notes in operating theatres, and completing the diagnoses and codes in discharge summaries, will improve the accuracy of the data. This was confirmed by a prospective audit of discharge summary error, where the seniority of the doctor was inversely proportional to the errors made (2% of consultant discharge summaries contained errors, compared with 7% for the senior registrars, 10% for registrars and 17% for senior house officers) [6].…”

“…We identified several studies which addressed this issue; 10% of discharge summaries in a vascular unit over an 8-month period contained errors, with 22% of these involving the diagnosis [6]. Mistakes were found in nearly a third of all the diagnostic codes in general surgery over the same period [7].…”

Difficult hospital discharges in internal medicine wards

“…Discharge summaries are important tools for communicating pertinent patient information regarding hospitalisations to outpatient care providers. Yet their relatively unstructured, narrative format often invites inaccuracies and errors [19]. In addition, there can be significant delays in transmitting discharge summaries to patients' health-care providers [20,21].…”