One in five discharge-summary actions went undone in general practice

Design

Retrospective cohort record analysis across seven general practices

Population

263 patients aged 65 or older discharged over one year; 551 requested actions

Primary outcome

Discharge-action errors, harms and 90-day readmission

Effect

Errors 20.6% and harm 4.4% of patients needing action; 90-day readmission 17.5% (95% CI 13.7-23.0)

A retrospective record review across seven UK general practices examined how discharge summaries for patients aged 65 and older were acted on, covering 263 patients discharged over a year and 551 requested actions in 160 summaries.

Of patients who required an action, 20.6% experienced an error (a requested action not completed) and 4.4% experienced harm; most harms led to readmission and several were judged preventable in primary care. The 90-day related readmission rate was 17.5%. Errors and harms fell disproportionately on patients with dementia or a recorded carer.

The practical change is procedural: practices should look hard at how discharge summaries are received, triaged and actioned, with a reliable system for completing requested tasks and extra safeguards for the most vulnerable patients. The sample is small and purposive, so the exact rates are indicative, but the direction, that discharge processing is a real safety gap, is the usable message.

• One in five requested discharge actions were not completed for older patients.
• Harm occurred in 4.4%, with most harms leading to readmission.
• The 90-day related readmission rate was 17.5%.
• Patients with dementia or a recorded carer were disproportionately affected.
• Review how your practice receives, triages and completes discharge-summary actions.

Why it matters

It locates a preventable source of post-discharge harm squarely in primary-care processing, not just in the hospital letter.

Don't overread it

A small, purposively sampled record review; the precise rates may not generalise, and associations with dementia are observational.

The statistics, in plain English

These are observed rates from a small purposive sample, so treat the exact percentages as indicative; the consistent signal is that a meaningful share of discharge actions are missed and some cause harm.

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