HSIB investigation: Access to critical patient information at the bedside (2 February 2023)

Summary

This investigation by the Healthcare Safety Investigation Branch (HSIB) aims to improve patient safety by supporting staff to access critical information about patients at their bedsides in emergency situations. It defines critical information as ‘information about patients that needs to be accessed rapidly and accurately to ensure correct care is delivered when it is required’. In this investigation, critical information was considered through a focus on patient identifiers (such as name and date of birth) and decisions relating to whether someone is recommended to receive cardiopulmonary resuscitation (CPR) if their heart stops (cardiac arrest).

The reference event for this investigation was the care of a patient in a hospital who was found unresponsive in bed. A short time later, he stopped breathing and his heart stopped. Help was immediately sought from the ward staff and a team gathered around the patient’s bed, where they confirmed the patient’s identity and noted that a decision had been made that he was not recommended to receive CPR if his heart stopped. As a result, CPR was not started.

Around 10 minutes later, a nurse who had previously been caring for the patient returned from their break and recognised that the patient had been misidentified as the patient in the next bed. The patient whose heart had stopped was recommended to receive CPR. CPR was immediately started, but despite this, the patient died.

Content

The investigation found that misidentification of the patient, and limited access to critical information about the patient at the bedside delayed his treatment. The investigation identified factors that contributed to the event. These included:

• access to computer systems
• the display of information around the bed
• the sharing of information among staff to support familiarity with their patients.

Findings

• Clinical staff are not always able to access accurate, critical patient information at bedsides to support decision making in emergencies.
• Patient identity wristbands are not consistently checked by staff during the undertaking of clinical tasks.
• The expectations of how staff should identify patients in an emergency and access critical information in relation to their care cannot always be met in practice because of limitations of technology and the work environment.
• Concerns around confidentiality can prevent the display of critical patient information at bedsides that may be needed to support safe care, particularly in emergencies.
• What and how critical patient information is displayed at the bedside varies across hospitals, with differences in positioning, visibility, readability and legibility.
• There is no national guidance to support consistency and visibility of critical patient information on low-technology displays (whiteboards/posters) or high-technology displays (via digital systems).
• Lighting on hospital wards can make it difficult for staff to see critical patient information, either through too little light, or too much light causing glare.
• Clinical staff consistently report difficulties accessing digital systems because of limited or poorly functioning hardware. This can result in the use of less reliable, paper-based systems for accessing critical patient information.
• Limited interoperability of multiple digital systems means critical patient information may not be accessible or consistent across all systems used in the care of a patient. Staff need to know which systems contain the information they need.
• Limited ability at a national level to influence the functionality of digital systems and their procurement means healthcare organisations are implementing systems with varying design and functionality.
• At the hospital level, the configuration of electronic patient record systems can introduce further safety risks where the infrastructure and staff training needs necessary for successful implementation have not been fully considered, and the needs of the clinical users have not been fully established.
• There is variation in the words and symbols used to indicate CPR recommendations, and in the level of understanding of CPR recommendations across hospitals, that may influence responses to cardiac arrests.
• Nursing handovers (where information about patients is passed between nursing staff at shift changes) may not provide the information staff need to care for their patients because of where and how they are undertaken. There is no national guidance on how best to undertake handovers of care.
• The implementation of electronic handover systems in clinical workplaces is limited by digital infrastructure, and systems that do not meet the needs of their users.

Safety recommendations

HSIB makes the following safety recommendations.

Office of the National Data Guardian

HSIB recommends that the Office of the National Data Guardian supports local interpretation of the Caldicott Principles to give organisations and staff the confidence to display full patient names at the bedside to support correct patient identification for safer care.

NHS England

• HSIB recommends that NHS England develops guidance to providers, via any digital maturity assessments that are developed, to help ensure critical patient information (such as patient identifiers and cardiopulmonary resuscitation status) is available to clinical staff when accessing electronic patient record systems.
• HSIB recommends that NHS England provides guidance to healthcare organisations to support local design and configuration of electronic patient records to enable end users to access critical patient information (such as patient identifiers and cardiopulmonary resuscitation status).
• HSIB recommends that NHS England, during review of relevant Health Building Notes and Technical Memoranda, includes, as a consideration, that bedside patient information should be consistently visible.
• HSIB recommends that NHS England assesses the priority, feasibility, and impact of future research into what and how critical information pertaining to the emergency care of patients in the acute hospital setting can be readily and reliably accessed at a patient’s bedside.

Resuscitation Council (UK)

• HSIB recommends that the Resuscitation Council UK clarifies and promotes expectations around the sharing, presentation, and language of cardiopulmonary resuscitation recommendations in hospital ward environments in line with the findings of this investigation.

British Standards Institution (BSI)

• HSIB recommends that the British Standards Institution, with support from relevant stakeholders, provides symbology to standardise how information relating to a patient’s resuscitation status can be displayed in digital systems.

Royal College of Nursing

• HSIB recommends that the Royal College of Nursing develops guidance for ward-based nursing handovers with consideration of the following: how handovers are organised, their content, the environment in which they take place and the technology needed to support them.

Safety observations

HSIB notes the following safety observations.

• It may be beneficial for healthcare organisations to provide guidance to support decisions in clinical areas that balance confidentiality and the visibility of critical patient information for patient safety.
• It may be beneficial for healthcare organisations to assess their information technology infrastructure needs, such as equipment availability and network coverage, to enable staff to consistently access critical patient information.
• It may be beneficial if the language used to refer to cardiopulmonary resuscitation recommendations is standardised and clarified through the implementation of the Recommended Summary Plan for Emergency Care and Treatment.