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DISCHARGE SLIP ERRORS

ORIGINAL

PROF-563

PROSPECTIVE STUDY OF DISCHARGE SLIP

ERRORS

Dr. Muhammad Ahmad M.B.B.S

Additional Registrar Surgical Unit II
Bahawal Victoria Hospital
Quaid-e-Azam Medical College, Bahawalpur

ABSTRACT
BJECTIVE: To study the different types of errors made in discharge slips and analyzing various
reasons for that. DESIGN: Prospective study. SETTING: Surgical unit II, Bahawal Victoria
Hospital, Bahawalpur. DURATION OF STUDY: From 01-02-2000 to 30-11-2000.
METHODS: 566 discharge slips were presented in follow-up clinic and were analyzed. Any
error in discharge slip was identified and noted and separate record of each month was kept. RESULTS:
119(21%) discharge slips out of 566 contained 156 errors. These comprised 45(29%) general errors,
15(10%) diagnostic errors, 33(21%) operation data errors, 19(12%) cases of insufficient clinical text,
27(17%) missed complication and 17(11%) concerning follow-up. CONCLUSION: Given that all the
discharge slips are currently prepared by junior staff, this study suggests that verification of the accuracy of
clinical data should be made essential and user-friendly computers should be used for data collection and
audit.

KEY WORDS:

Discharge slips, Errors , Audit

INTRODUCTION

MATERIALS & METHODS

Discharge slips have a very important role in

medical practice. A considerable emphasis is
directed to patients morbidity and mortality,
surprisingly little emphasis is given on ensuring the
dissemination of correct information contained in
discharge slips1.

Surgical unit II of Bahawal Victoria Hospital

Bahawalpur (staffed by one Professor, two
Assistant Professors, seven Post Graduate Residents
and six House Surgeons) provides the general
surgical services to patients
Patients discharged from the unit are given a
discharge slip detailing patients particulars,

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diagnosis, treatment, operation notes, post-upcourse and medication. This system has been in use
in most of the hospitals of Pakistan. The discharge
slips are prepared by house surgeons and then
checked & countersigned by a Post Graduate
Resident.
Between 01-02-2000 and 30-11-2000, a prospective
study was undertaken for evaluation of accuracy of
566 discharge slips which were presented for
follow-up in OPD. Any error in the discharge slip
was identified and separate record of each month
was kept.
RESULTS
After review, 119(21%) discharge slips out of 566
were found to contain 156 errors including 45(29%)

DISCHARGE SLIP ERRORS

general errors, 15(10%) diagnostic errors, 33(21%)

operation data errors, 19(12%) cases of
incorrect/insufficient clinical text information,
27(17%) missed complication and 17(11%)
concerning follow-up.
General errors (n=45) included: wrong patient name
(n=2), wrong patient age (n=9), wrong patient
address (n=5), wrong registration No (n=3), wrong
description of symptoms (n=8), wrong clinical
findings (n=4), wrong responsible surgeon (n=7)
and failure to copy on discharge slip from the
inpatient chart (n=7).
Diagnostic errors (n=15) were made in two ways
(table-1): incorrect diagnoses (n=6) and missed
diagnoses (n=9).

Table - 1. DIAGNOSTIC ERRORS

MISSED DIAGNOSES (N=9)
Colonic carconoid tumour

Retroperitoneal haematoma

Intestinal TB (n=2)

Interloop abscesses

Mesenteric lymphadenitis

Perforated appendix

Colonic carcinoma

Varicose veins
INCORRECT DIAGNOSES (N=6)

Incorrect

Correct

Appendicitis (n=2)

Mesenteric lymphadenitis

Femoral hernia

Inguinal hernia

Inguinal hernia

Recurrent inguinal hernia

Para umbilical hernia

Umbilical hernia

Groin swelling

Infected haematoma

Operative data errors (n=33) pointed out (table-2)

included: wrong operation (n=5), missed operation
(n=9) and failure to mention important intraoperative findings (n=19). 19 discharge slips with
incorrect clinical text information mentioning
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wrong side of pain in renal stone (n=2) and wrong

medication given (n=2), failure to disclose
important investigations result (n=4), failure to
mention result of biopsy report (n=3) and wrong
findings of clinical examination (n=5). Important

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complications were omitted in 27 cases including

general complications (n=11) and specific
Table - 2.

DISCHARGE SLIP ERRORS

complications (n=16) table -3.

OPERATIVE DATA ERRORS

Missed operations (n=9)

Fasciotomy

Bladder neck resection

Split skin grafting (n=2)

Urethral dilation

Enucleation of fibroadenoma breast

Enucleation of lipoma

Below knee amputation

TURP
WRONG OPERATION (n=5)

Incorrect

Correct

Colostomy

Ileostomy

Loop ileostomy

Double barrel ileostomy

Cholesysstectomy

Cholecystostomy

Appendicectomy

Drainage of appendicular abscess

TVP

Bladder neck resection

INTRA OPERATIVE FINDINGS NOT LISTED (n=9)

Blunt abdominal trauma: retroperitoneal haematoma

Intestinal obstruction ; internal hernia
Intestinal obstruction: adhesions and bands (n=3)
Acute appendicitis: perforated appendix (n=3)
Acute appendicitis: mesenteric lymphadenitis

Regarding follow-up, 5 patients were given wrong

follow-up date, 7 were discharged without
mentioning the date and day for follow-up, 3 were
given un-necessary review appointment while 2
patients were not directed to consult the surgeons in
their localities (i.e., one in Rahim Yar Khan and
one in Sadiq Abad).
Table - 3. Missed complications
(i)

General complications (n=11)

Pyrexia (n=2)
Transfusion reaction (n=3)

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Aspiration pneumonia (n=1)

Wound infection (n=3)
Chest infection (n=2)
(ii)

Specific complications (n=16)

Scrotal haematoma after herniorrhaphy (n=2)

Graft rejection (n=2)
Hernial recurrence (n=1)
Subphrenic abscess after laparotomy (n=1)
Facial nerve palsy after superficial parotidectomy (n=1)
Tetany after subtotal thyroidectomy (n=1)
Recurrent nerve paralysis after subtotal thyroidectomy (n=1)
Biliary leak after cholecystectomy (n=1)
Skin excoriation after ileostomy / colostomy (n=3)
Prolapse after ileostomy / colostomy (n=1)

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Post TURP incontinence (n=2)

increasing workload on house surgeons, they find it

difficult to write down the long, lengthy discharge
slip notes.

DISCUSSION
The performa type discharge slips are
comprehensive and helpful in follow-up visits.
Many errors are clinically important with
implications on patient care. Furthermore these
have financial (and sometimes) medico legal
implications2.
The impression of a unit is dependent, partly, on the
quality of information provided in discharge slips.
Poor quality discharge slips with mistakes (obvious
and disguised) reflect poorly on the unit from which
they originate. In this unit, all the discharge slips
were prepared by the House Surgeons.
In over 75% of the discharge slips, the information
was adequate. There is no such data available to
compare with those received from a medical or
other surgical unit. However the ratio of discharge
slip errors was much lower (17%) in a study carried
out in a department of vascular surgery in UK2.
Only 33% of the total discharge slips (during 8
months) were produced in that study by the House
Surgeons which contained 17% of the errors as
compared to 21% errors disclosed in this study in
which 100% of the discharge slips were prepared by
the House Surgeons.
Failure to document complications like scrotal
swelling, sepsis, skin excoriation etc may result in
delay in management of these patients with a
resultant increased morbidity. Incomplete clinical
text and operative findings make it difficult for
doctors in follow-up to recognize the severity of
disease. Incorrect clinical appointment results in
inconvenience for patients. Poor prescription
advice, particularly, concerning antibiotics and
NSAIDs is potentially dangerous.
The reasons for these errors are multiple. With

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Disordered case notes with multiple entries can

make it difficult to identify relevant facts. The
written operation notes may not have found their
way to case notes by the time of discharge slip
operation. Many juniors cannot relate to the
importance of accurate case notes, and when faced
with a pile of discharges, may be careless in making
the effort to identify specific finding. In addition,
the responsible PGRs do not take it seriously to
check the discharge slips thoroughly. Moreover
handwriting of original notes certainly has some
effect while copying on discharge slips.
Finally there is no way to keep the full record of
inpatients. The access to the admission chart is a
very lengthy procedure. Lack of computerization is
another major factor. Errors of patients details and
procedures could potentially be avoided if these
could be stored in computers. This is possible by
transferring the full data and details on a floppy disc
and making a record of each month.
The potential of errors are inversely related to
clinicians grade2. It is important when it is
considered that majority of the discharge slips in
this unit (and probably in the country) are prepared
by junior staff. Although countersigned by PGRs,
yet this emphasizes the importance of some other
method of verifying the contents of discharge slip
summaries.
In addition to verifying discharge slips, weekly (at
least monthly) meeting should be practised to point
out the errors of previous week or month. This can
result in filling the gap between junior and senior
staff, juniors education and better patients care.
Patient discharge slips should be prepared by
someone familiar with the patient. Complex

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summaries should be dictated by the responsible

surgeon.
Furthermore, the surgical trainees (PGRs) should be
educated in the use of, and benefits from an
accurate local database. The computerization of the
units should be started now. Because the advent of
user-friendly, affordable personal computer has
allowed the easy analysis of large amounts of data
and has the added advantage of allowing the
generation of standardized discharge summaries3,4.

DISCHARGE SLIP ERRORS

1.

Pears J, Alexander V, Alexander GF, W aught NR.

Audit of the quality of hospital discharge data.
Health Bulletin 1992; 50: 356-61.

2.

Macaulay EM, Cooper GG, Engeset J, Naylor AR.

Prospective audit of discharge summary errors. Br.
J. Surg. 1996; 83: 788-90.

3.

Dunn DC. Audit of a surgical firm by

microcomputer: five years experience. BMJ 1988;
296: 687-91.

4.

Llewelyn DE, Ewins DL, Horn J, Evans TG,

McGregor AM. Computerized updating of clinical
summaries: new opportunities for clinical practice
and research BMJ 1988; 297: 1504-6.

REFERENCES

Life is Gods greatest gift;

Use it following him
Shuja Tahir

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