Major theme | Sub-theme |
---|---|
Communication failures | âą Care home not informed of discharge âą Difficulty booking transport âą Discharge letter contained incorrect information âą Handover not completed properly âą Referral to other services not made âą Discharged without test results |
Delayed discharge | âą Result of communication error during booking of transport âą Family cause of a delay âą Internal delays to medication âą Patient transport service aborted or late |
Documentation | âą Missing documentation âą Incomplete documentation âą Mistake in documentation âą Received wrong patientâs documentation (data breach) |
Medication | âą Inappropriate medication âą Incomplete medication âą Incorrect dosage / prescription / dispensation âą Missing or lost medication âą Patient received someone elseâs medication |
Pressure ulcers | âą Identified prior to discharge âą Identified after discharge |
Devices / equipment | âą Device left in situ after discharge âą Incorrect equipment given to patient |
Staffing shortages | No sub-theme |
Patient actions | âą Verbal/physical aggression or harassment âą Self-discharge against advice âą Patient refused discharge |