Safety Body Warns Over Post-Discharge Information Gaps

Communication failures between hospitals and community services after patient discharge can lead to serious medication-related harm, a new report has warned.

The Health Services Safety Investigations Body (HSSIB) found that gaps in patient records, poor information sharing, and insufficient post-discharge support can delay or prevent medication being taken, with potentially life-threatening consequences.

Case Study: Missed Insulin After Discharge

The investigation examined the case of a 53-year-old man whose diabetes medication was changed during a hospital stay. 

Although he received some education on self-administering insulin, he later said he struggled to remember the instructions. A referral for district nursing support was made via his GP, but the district nursing team was not informed. 

Seventeen days after discharge, he told a nurse that he had not been taking insulin. His glucose levels were dangerously high, leading to an emergency hospital readmission.

Key Failings Identified

The HSSIB identified several failings:

• Conflicting records on admission made it unclear whether the patient had been taking diabetes medication.
• No documented evidence confirmed his ability to self-administer insulin after discharge education.
• Communication about the need for district nursing support was inconsistent between hospital teams and community services, and no specific support for insulin administration was arranged.
• The patient was discharged with two insulin pens, one of which was unnecessary, causing him confusion.
• District nursing demand often exceeded capacity, limiting visit times.
• Multiple providers used incompatible electronic patient record systems, preventing the sharing of critical information.

Recommendations for Safer Discharges

The report calls for local-level learning prompts covering hospital care, discharge planning, and community follow-up to prevent similar risks.

It stressed the importance of ensuring patients are confident in managing their medication before leaving hospital and improving interoperability between hospital and community electronic systems.

‘A Matter of Patient Safety’

Rebecca Doyle, safety investigator at HSSIB, said that improving information flow and patient support at discharge is more than an administrative task.

“It’s a matter of patient safety,” she said. “While individual cases can be complex, this incident clearly highlighted persistent challenges with information sharing – an issue we continue to see in investigations that explore communication and the interaction of digital systems. This information sharing is critical to keep people safe at home, managing their medical conditions, and avoiding readmission to hospital.”

The report is the third and final in a series of HSSIB investigations exploring why medications intended to be given to patients were not given. 

Priscilla Lynch is a freelance writer for Medscape, with over 20 years’ experience covering medicine and healthcare. She has a master’s in journalism and recently undertook a Health Innovation Journalism Fellowship with the International Center for Journalists.