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Updated: Dec 15, 2025

Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform
Published on: April 12, 2021
Improving patient follow-up after inpatient stay
1Ashford and St Peters NHS Foundation Trust.
Abstract:
Follow-up is a vital part of ongoing patient safety. It allows for subsequent investigations to be checked and acted upon, encourages specialist review of patients and ensures that patients with chronic conditions receive the appropriate secondary care input. This study aims to highlight and quantify current problems with how follow-up arrangements are made within our hospital and provide a suitable solution to ensure that these problems are minimised. 20 sets of clinical notes were analysed for plans of follow-up and then compared with the discharge summaries produced. Hospital computer systems were used to find out which interventions happened, and when, to get the baseline data. A simple follow-up prompt sheet was introduced and a further 20 sets of notes were audited to complete the study. Patient follow-up improved after the introduction of a simple follow-up prompt sheet but highlighted the need for a complete change in the way follow up is arranged at our hospital. There is a need for an online system for requesting follow-up appointments in our hospital. This is vital given the 24 hour environment that we work in with many patients being discharged out of normal working hours. This is currently being discussed with management and we hope that the introduction will be imminent to improve the future safety of all patients.
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