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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