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Table 3 proposed solutions to safety challenges discussed at FMEA meeting

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

Safety challenge Solutions
Routine difficulties with access to medical records in post discharge clinics leads to decisions being made without adequate background information • 'Electronic' patient record (long term)
• Patient held record – e.g. of consultants seen
• Centralised record tracking system
• Routine access to both sets of notes for post discharge clinics.
• One set of notes rather than multiple
• Notes available on IT systems
• Patients to have high quality discharge summary
• Cross city database to hold patient data, generate letters – access could be available in clinics and would hold more information than discharge summary
For a variety of reasons, information about discharged patients sometimes does not reach relevant primary care staff AND Patients are at risk when medication changes during admission are not communicated to primary care • Patient held copy of discharge letter/fax
• Extra copy in 'system'
• Ask primary care if there are other ways that they think might work better, e.g. phone call for each individual patient with their GP/practice nurse (5–10 people per week – up to 6 calls per individual patient needed)
• Direct professional phone line into practices
• Respiratory directory – useful information to help contact, e.g. phone numbers, etc
Difficulty in communicating with the bed bureau can put patients at risk • Increase number of telephone lines
• Audit/monitor bed bureau response times, how easy it is to get through, etc.
• Use of emergency care practitioners – send them to have a look to assess, make decisions re Fast Track Supported Discharge care
• Tell Bed Bureau that patients/staff can't get through (formally? informally?)
• Implement phone system logging ability etc. as per 999 systems
• Implement telephone queuing system