Prospective audit of discharge summary errors

Abstract

Abstract During an 8-month interval of prospective audit, 63 of 637 (10 per cent) vascular discharge summaries were found to contain 94 errors. These comprised 11 (12 per cent) general errors, 21 (22 per cent) diagnostic errors, 19 (20 per cent) operative data errors, 19 (20 per cent) cases of incorrect clinical text information, 14 (15 per cent) missed complications and 10 (11 per cent) concerning follow-up arrangements. Overall, 2 per cent of consultant discharge summaries contained errors compared with 7 per cent for the senior registrar, 10 per cent for registrars and 17 per cent for senior house officers. Given that the majority of discharge summaries are currently prepared by junior staff, this study suggests that verification of the accuracy of clinical and management data should be an essential component of departmental audit meetings.