Table 2.

Reasons for patient’s poor preparation for discharge to home and/or hospital readmission.

Theme	Description	Patient Quotes
People: Patient’s and caregiver’s expectations and understanding	Inadequate understanding or expectations of the patient/caregiver Inability of patients to understand and have realistic expectations of their needs or consequences related to surgery and care post-discharge	“we just wanted to make sure that we are doing what is right here and whether we should continue with the medicine or not…” “we ran out of options…because I didn’t know what to do for her” “I didn’t really know what questions to ask, I think that is the other hard part. For not being a surgery patient ever before in my life, I had no idea what to expect.”
Tasks: Discharge preparation	Timing or magnitude of changes before discharge impedes patient receiving sufficient discharge instructions	“…new medications I had to reference…there were just so many changes…” “There was plenty of time earlier to go over my information…”
Tasks: Educational process	Inadequate or incomplete instruction that negatively impacts patient’s care at home	“The only problem was that I didn’t know how to use my (J-tube)…I think that I should have been taught a little bit more about that here.” “They should have spent more time on liquids and full liquids in comparison to eating solids. Because I think that lead to eating too much food in my stomach or in my colon that I couldn’t get rid of…”
Tools & Technology: Content of education materials	Aspects of the content of educational materials to be used at home that impeded teaching, understanding or use	“We had so much paperwork…” “It would have been nice to have a specific contact…all they do is give you some general information about what to do…”
Organization: Care team organization	Aspects of care team communication, practice, structure/roles that may interfere with care and preparation for patient’s discharge	“I think there…there was a lot of people that…I was glad that I was getting everyone’s opinions, it was just um trying to get every-one’s opinions together…I think that getting on the same page took…a little bit of time.” “I don’t think that anybody called but it would have been nice…you know if someone would have called and said do you have any concerns”
Service coverage	Inadequate after business-hours coverage at the academic center for services required by the patient that adversely impacts care or preparation of patient’s home care/discharge	“The lady had said that within the hour I should get a call back from one of the resident doctors and I had not gotten a call back…”
Outside clinician support	Lack of clinical or procedural expertise to manage patient outside the academic center	“I went to my hospital, where my primary physician is and they said that they weren’t capable in handling my type of…they’re just a small hospital they said and they didn’t want to…they couldn’t do my…care there because they were not familiar with it…”
Insufficient home health services or equipment	Insufficient or unknown home health services negatively affects care or preparation for care at home Lack of awareness of home equipment negatively affects care or preparation for care at home	“So unfortunately the nurses can only come once a day…awe, so that really didn’t work for me…” “I think the hospital needs to do is to help people like me …develop a …core team to check on people…”

SEIPS, System Engineering Initiative for Patient Safety