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Table 5 Themes and sub-themes of staff incident reports (n = 92) relating to patient discharges

From: Implementing a survey for patients to provide safety experience feedback following a care transition: a feasibility study

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