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Table 2 Type of safety problem ranked by mean score on a visual analogue scale

From: Using a multi-method, user centred, prospective hazard analysis to assess care quality and patient safety in a care pathway

N Safety problem descriptor Mean score/10
1 Routine difficulties with access to medical records in post discharge clinics leads to decisions being made without adequate background information 6.9
2 For a variety of reasons, information about discharged patients sometimes does not reach relevant primary care staff 6.8
3 Patients are at risk when medication changes during admission are not communicated to primary care 6.0
4 The service is vulnerable during periods of staff sickness, which may also affect staff morale 5.5
5 Difficulty in communicating with the bed bureau can put patients at risk 5.4
6 The provision of a differential service across the two hospitals may lead to a variation in the quality of the care provided 5.2
7 Some primary care staff appear to be unsure of the aim of the supported discharge programme, and of the care provided 5.0
8 Patients are at risk when patients do not bring their home care treatment/record with them on re-admission 5.0
9 Making and keeping hospital appointments can be a problem 4.9
10 Lack of clarity on the part of non-COPD Hospital Staff about the re-admission process leads to quality variation and admission delays, misdirection of patients and inefficiencies 4.6
11 Technical difficulties with telephone communications between staff and between staff and patients is a possible safety risk 4.5
12 Quality variation and inefficiencies occur because the COPD Supported Discharge Programme does not have a high priority, compared with other hospital services 3.8