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