- Design
- Retrospective record review cohort
- Population
- 263 patients aged ≥65 discharged to seven West Midlands general practices
- Primary outcome
- Errors and harms in actioning discharge requests; 90-day readmission
- Effect
- Error 20.6% and harm 4.4% among patients needing action; 90-day readmission 17.5%
This BJGP study reviewed the records of 263 patients aged 65 or over discharged from hospital to seven general practices in the West Midlands over a year. Discharge summaries for 160 of them asked the practice to do something — 551 actions in all.
Among patients who needed an action, 20.6% experienced an error, most often a requested action not completed, and 4.4% came to harm. Most harms led to readmission, and three in eight were judged preventable in primary care. Errors and harms fell disproportionately on patients with dementia or a recorded carer. Overall, 17.5% had a related readmission within 90 days.
The practical response is a reliable process, not more vigilance: a named person who reads every discharge summary, extracts each action, assigns it and checks it is done, with extra attention to patients who cannot advocate for themselves.
- Set up a practice process in which every discharge summary is read for actions within a fixed time.
- Track each discharge action to completion, not just to filing.
- Prioritise patients with dementia or a carer — they bore most of the errors and harm.
- Contact high-risk patients soon after discharge to check medicines and follow-up.
- Audit a sample of discharges to see how many requested actions were completed.
Why it matters
Readmissions are often blamed on hospitals, but this shows a share are preventable at the practice end of the handover.
Don't overread it
Seven purposively chosen practices and 263 patients — the error rate is an estimate, not a national figure.
The statistics, in plain English
The readmission rate of 17.5% has a 95% confidence interval of 13.7% to 23.0%, so the true figure in similar practices could be anywhere in that range.
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