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Practice number Description 1 An urban training practice in the East Midlands with an average list size using SystmOne 2 A suburban training practice in the East Midlands with a larger than average list size using SystmOne 3 A rural training practice in an affluent (IMD <10) area of the East Midlands, with a larger than average list size using SystmOne 4 An urban training practice in a socioeconomically deprived (IMD >40) area of the East Midlands with an average list size using Emis Web 5 A suburban practice in a socioeconomically deprived (IMD >40) area of the East Midlands with an average list size using SystmOne 6 An urban training practice in a socioeconomically deprived (IMD >40) area of the West Midlands with a smaller than average list size using Emis Web 7 An urban training practice in the West Midlands with an average list size using SystmOne 8 A suburban practice in the East Midlands with an average list size using SystmOne 9 A suburban training practice in the North West with a smaller than average list size using Emis Web 10 An urban training practice a socioeconomically deprived (IMD >40) area of the North West. ‘Super-surgery’ (list size >20 000) using Emis Web Practice 1 is the working site of GP1 and practice manager 1, practice 2 is the working site of GP2 and PM2, and so on. Where not stated, the practice had average IMD scores. Practices have been anonymised and randomly numbered to protect the identity of interview participants. IMD = index of multiple deprivation.
Participant code Age, years Sex UK graduate(GP) Graduation date Years as qualified GP Years in current profession (PM) Date interviewed Interview duration, mins GP1 56 M Yes 1984 25 NA 24/05/2017 54 GP2 38 F No 2000 6 NA 22/11/2016 42 GP3 38 M Yes 2004 6 NA 11/01/2017 39 GP4 38 F Yes 2003 8 NA 16/11/2016 39 GP5 52 M Yes 1988 24 NA 08/12/2016 62 GP6 38 M No 2000 9 NA 10/05/2017 53 GP7 39 F Yes 2004 9 NA 01/03/2017 33 GP8 49 F Yes 1991 22 NA 25/01/2017 29 GP9 36 F Yes 2006 5 NA 09/03/2017 48 GP10 60 M Yes 1982 25 NA 19/04/2017 48 PM1 61 F NA NA NA 23 22/6/2016 36 APM2 28 F NA NA NA 1 22/11/2016 34 APM3 59 F NA NA NA 20 11/01/2017 38 PM4 50 F NA NA NA 25 16/11/2016 30 APM5 55 F NA NA NA 37 08/12/2016 43 PM6 67 F NA NA NA 15 10/05/2017 54 PM7 53 M NA NA NA 2 01/03/2017 43 PM8 61 F NA NA NA 9 25/01/2017 37 PM9 52 F NA NA NA 8 09/03/2017 39 APM10 45 M NA NA NA 22 19/04/2017 35 Practice 1 is the working site of GP1 and practice manager 1, practice 2 is the working site of GP2 and PM2, and so on.
APM = assistant practice manager. NA = not applicable. PM = practice manager.
- Box 2. Main themes and subthemes (subthemes in brackets are not reported on in this article)
1. Secondary care factors: ‘ideal’ discharge summary, delegation, (safety of transfer and NHS pressures)
2. Safety features of discharge summary processing systems: continuity of care, (team-working), protocols and procedures, training, staff numbers, and workflow targets
3. Medicines reconciliation: communication with patients, (medicine and/or patient related factors), pharmacy intervention, and prescribing roles
4. Error and harm as a result of faulty processing of discharge summaries: causes of error and/or harm, time and/or workload pressures, communication about error and/or harm, and harm severity and/or preventability
5. Strategies for safety improvement: administrative, IT and prescribing systems, significant event analyses, (the unplanned admissions scheme), and (direct impacts of the project) Discharge summary design Standardised structure
‘GP action' box
Alphabetisation of medications listing
Highlight changed medication (for example by using standard codes)
Do not allow ‘hand annotations’
On-the-day workflow system for electronic documents
Priority scanning for paper discharge summaries
Priority flag discharge summaries within the electronic mailbox
Protected time and workspace for administrators involved in processing discharge summaries
Aim for usual or referring GP to process the discharge summary unless this will lead to potentially hazardous delay
Prioritise higher-risk patients and/or carers to contact for medications reconciliation
Consider making free-text entries about clinical decisions taken after reading the discharge summary (this could be recorded at the place where the discharge summary document can be seen in the facing electronic record)
Consider using a clinical pharmacist to assist with medicines reconciliation
Use IT to track actions; for example, electronic tasks, coded actions, diary functions
Protected time and workspace for GPs and other colleagues involved in taking action in relation to requests in discharge summaries
Enable visualisation of discharge summary and electronic health record at same time (split screen or two screens)
Consider creating a template or consultation style in the electronic record (where possible, Read coded) to process the discharge summary; for example, data-entry points for diagnosis, significant test results, medication changes, discussions with patients and/or carers, and outstanding actions
Interoperability of primary and secondary care IT systems to allow for co-creation of the discharge summary. GPs would be able to comment on medication changes and requests for action prior to the patient being discharged
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