Compliance with the Health Information and Quality Authority of Ireland National Standard for Patient Discharge Summary Information: a retrospective study in secondary care

Abstract

BackgroundUnexplained changes to medication are common at hospital discharge and underscore the need to standardise patient discharge clinical documentation. In 2013, the Health Information and Quality Authority in Ireland published a Standard on the structure and content of discharge summaries. The intention was to ensure that all necessary information was complete and communicated to the next care provider.ObjectivesThis study investigated one Hospital's compliance with the Standard, and appraised two methods of electronic discharge communication (Symphony or Tallaght Education and Audit Management System (TEAMS)).MethodA retrospective survey of 198 randomly selected discharge summaries was conducted at the study hospital, a 600 bed academic teaching hospital located in Dublin, Ireland.ResultsOf the 198 evaluated summaries, mean total compliance was 77%±4.2 (95% CI 76.3 to 77.5). Most (84.7%, n=173) summaries were completed using one of the systems (TEAMS). Absence of communication about alteration of preadmission medication was frequent (107 out of 130 patients (82.3%, CI 76.2 to 89.2)). Higher compliance rates were observed however, when information was interfaced or where there were dedicated fields to be completed.ConclusionsEfforts to improve compliance with the National Standard for Patient Discharge Summary Information should focus on reporting changes made to medication during hospitalisation.

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“…Enabling the digital sharing of prescription information across care settings could reduce the prevalence of information transfer errors and the associated risk of avoidable harm to patients. [10][11][12] The development of interoperable systems to facilitate digital medicines reconciliation has shown promise in reducing time taken to complete the process and to further reduce unintentional discrepancies, mostly focused on hospital admission and discharge. 13 14 However, previous work is based on small-scale, qualitative or review studies, and/or relate to electronic prescribing interventions which are not fully interoperable.…”

Structure, content, unsafe abbreviations, and completeness of discharge summaries: A retrospective analysis in a University Hospital in Austria

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