Enhancing Patient Safety Through Improved Discharge Documentation: A Quality Improvement Audit at Hasahesa Teaching...

Effective discharge documentation is essential for ensuring continuity of care and patient safety. In many resource-limited hospitals, discharge summaries are often incomplete, leading to communication gaps, preventable errors, and avoidable readmissions. This audit evaluated the impact of introducing a standardized discharge card on the quality of discharge documentation at Hasahesa Teaching Hospital, Sudan.

A two-cycle clinical audit was conducted in the Internal Medicine Department. The baseline review (Cycle 1) assessed 50 discharge cards retrospectively over a two-week period (20 March to 2 April 2025) using a structured checklist adapted from international standards. Following this, a one-month intervention was implemented, introducing a newly designed discharge card supported by staff training and visual aids. The re-audit (Cycle 2) reviewed 50 discharge cards over three months (3 May-2 August 2025). Compliance across multiple documentation domains was compared using the chi-square test.

Documentation improved significantly across all domains after the intervention. Recording of demographic details, clinical information, treatments, discharge diagnosis, and follow-up instructions rose from baseline levels of 22-56% to post-intervention levels of 94-100%, representing absolute improvements of 38-72 percentage points (95% CIs provided in the full text). All improvements were statistically significant (p < 0.001). Staff feedback indicated that the standardized card was clear, practical, and enhanced workflow.

The standardized discharge card markedly improved the quality and completeness of discharge documentation, providing a simple, low-cost, and effective intervention to strengthen patient safety and continuity of care in a resource-limited setting. Wider implementation and longer-term evaluation are recommended to ensure sustainability and scalability.