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Found 68 results
  1. News Article
    Pregnant women should be asked how much alcohol they are drinking and the answer recorded in their medical notes, new "priority advice" for the NHS says. The advice, from the National Institute for Health and Care Excellence (NICE), is designed to help spot problem drinking that can harm babies. Infants with foetal alcohol spectrum disorder (FASD) can be left with lifelong problems. The safest approach during pregnancy is to abstain from alcohol completely. The more someone drinks while pregnant, the higher the chance of FASD - and there is no proven "safe" level of alcohol. But the risk of harming the baby is "likely to be low if you have drunk only small amounts of alcohol before you knew you were pregnant or during pregnancy", the Department of Health says. An earlier draft of the recommendations for NHS staff in England and Wales suggested transferring data on a woman's alcohol intake to her child's medical notes - but this has now been dropped, following concern women who needed help might hide their drinking. The Royal College of Midwives spokeswoman Lia Brigante said: "As there is no known safe level of alcohol consumption during pregnancy, the RCM believes it is appropriate and important to advise women that the safest approach is to avoid drinking alcohol during pregnancy and advocates for this. "We are pleased to see that the recommendation to record alcohol consumption and to then transfer this to a child's record has been reconsidered. "This had the potential to disrupt or prevent the development of a trusting relationship between a woman and her midwife." Read full story Source: BBC News, 16 March 2022
  2. News Article
    Medical records contain a plethora of information, from a patient’s diagnoses and treatments to marital status to drinking and exercise habits. They also note whether a patient has followed medical advice. A health provider may add a line stating that the patient is “noncompliant” or “non-adherent,” signalling that the patient has been uncooperative and may exhibit problematic behaviours. Two large new studies in the US found that such terms, while not commonly used, are much more likely to appear in the medical records of Black patients than in those of other races. The first study, published in Health Affairs, found that Black patients were two and a half times as likely as white patients to have at least one negative descriptive term used in their electronic health record. About 8% of all patients had one or more derogatory terms in their charts, the study found. The most common negative descriptive terms used in the records were “refused,” “not adherent,” “not compliant” and “agitated.” The second study, published in JAMA Network Open, analysed the electronic health records of nearly 30,000 patients at a large urban academic medical centre between January and December 2018. The study looked for what researchers called “stigmatising language,” comparing the negative terms used to describe patients of different racial and ethnic backgrounds as well as those with three chronic diseases: diabetes, substance use disorders and chronic pain. Overall, 2.5% of the notes contained terms like “nonadherence,” “noncompliance,” “failed” or “failure,” “refuses” or “refused,” and, on occasion, “combative” or “argumentative.” But while 2.6% of medical notes on white patients contained such terms, they were present in 3.15% of notes about Black patients. Looking at some 8,700 notes about patients with diabetes, 6,100 notes about patients with substance use disorder and 5,100 notes about those with chronic pain, the researchers found that patients with diabetes — most of whom had type 2 diabetes, which is often associated with excess weight and called a “lifestyle” disease — were the most likely to be described in negative ways. Nearly 7% of patients with diabetes were said to be noncompliant with a treatment regimen, or to have “uncontrolled” disease, or to have “failed.” The labels have consequences, warns Dr. Schillinger, who directs the Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center. “Patients whose physicians tend to judge, blame or vilify them are much less likely to have trust in their doctors, and in the medical system overall,” Dr. Schillinger said. “Having health care providers who are trustworthy — who earn their patients’ trust by not judging them unfairly — is critical to ensuring optimal health and eliminating health disparities.” Read full story (paywalled) Source: The New York Times, 20 February 2022
  3. Content Article
    This article, published in the International Journal for Quality in Health Care, explores the usage of participatory engagement in patient-created and co-designed medical records for emergency admission to the hospital. It is advocated as a means to improve patient safety.
  4. Content Article
    This report by the Healthcare Safety Investigation Branch (HSIB) has been published as part of a local pilot, which has been launched to evaluate HSIB’s ability to carry out effective investigations occurring between specific hospitals and trusts. After an evaluation, it will be decided whether this model can be implemented more widely by HSIB. On her admission to her local emergency department (ED) after a fall at her nursing home, Mrs E, a woman aged 93 with dementia, was booked into the ED with incorrect patient details, resulting in a new patient record being created. She was discharged that day but readmitted the next day after a second fall. She was booked into ED with the new patient record (which contained the incorrect patient details) and had an x-ray which confirmed she had a broken hip, subsequently being admitted to hospital for surgery. Mrs E had surgery the next day, during which the pathology department identified a problem with the accuracy of her patient identification information and following surgery her two sets of patient records were merged.
  5. Content Article
    This International Patient Summary roadmap (G7-IPS) supports the G7 commitment to deliver on the rights of patients to have access to their health information, and through using open and interoperable standards it enables this information to be used at the point of treatment or care. The roadmap outlines the component parts required for implementation and the standards which will be used to ensure alignment and interoperability across the G7 community. Although developed by the G7 countries, other countries, should they wish to, will be able to adopt the same principles and use the open and interoperable resources.
  6. Content Article
    This report by the Healthcare Safety Investigation Branch (HSIB) has been published as part of a local pilot, which has been launched to evaluate HSIB’s ability to carry out effective investigations occurring between specific hospitals and trusts. After an evaluation, it will be decided whether this model can be implemented more widely by HSIB. This investigation reviewed the case of a woman who was taken to an emergency department by ambulance in April 2021, following a 999 call from her Granddaughter to the emergency operations centre. The emergency operations centre used the wrong NHS number for the patient, which was assigned to her for the duration of her stay in hospital and led to her being offered incorrect medication.
  7. News Article
    From next month, patients will be able to access all new entries in their online health records, if their GP practice use TPP or EMIS IT systems. According to NHS Digital, patients who use online accounts – such as the NHS App – and whose surgery uses TPP, will be able to view entries from December 2021 onwards. While, patients on an EMIS system should expect to see theirs from ‘early 2022’. Practices which use the Vision system are still currently in discussions over access. NHS Digital says that patients will not be able to see specific personal information, such as positive test results, until they have been ‘checked and filed’, so that GPs have the opportunity to contact them first. The body adds that the move, ‘supports NHS Long Term Plan commitments to provide patients with digital access to their health records’, and also shares its aim for patients to be able to request their historic coded records from 2022, through the NHS App. As ’80 per cent of the 18 million NHS App users’ are said to want ‘easy access to their health records and personal information’, it’s hoped that the initiative will reduce queries around negative test results and referrals, and encourage patient awareness and empowerment in regards to their health. However, NHS Digital does advise General Practice staff to ‘be aware that patients will be able to see their future records’, and to ensure ‘sensitive information is redacted as it is entered’ into systems, with a support package and training sessions available to guide clinicians and staff in these areas. Read full story Source: Health Tech Newspaper, 5 November 2021
  8. Content Article
    On 11 June 2019 an investigation into the death of Brooke Martin aged 19 started. Brooke was a patient at Isla House, Chadwick Lodge, Milton Keynes and was detained under the Mental Health Act. She had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder. Brooke was found hanging in her room and was taken to Milton Keynes University Hospital where she died on 11 June 2019.
  9. Content Article
    'This is me' is a simple leaflet for anyone receiving professional care who is living with dementia or experiencing delirium or other communication difficulties. 'This is me' can be used to record details about a person who can't easily share information about themselves. For example, it can be used to record: a person’s cultural and family background important events, people and places from their life their preferences and routines.
  10. Content Article
    NHSX recently launched a brand new information governance portal providing a 'one-stop shop' for NHS policies and guidance. The new portal covers everything from GDPR in research to record management. But even with the new portal, navigating NHS guidance on data isn't easy. This article in Global Compliance News picks out six essential items to have on your radar if your organisation accesses or uses NHS data.
  11. Content Article
    NHSX has launched a brand new information governance portal providing a 'one-stop shop' for NHS policies and guidance.
  12. News Article
    A world-leading children’s hospital has been accused of a “concerted effort” to cover up the mistakes that led to the death of a toddler. Jasmine Hughes died at London’s Great Ormond Street Hospital aged 20 months after suffering acute disseminated encephalomyelitis (ADEM), a condition in which the brain and spinal cord are inflamed following a viral infection. Doctors said that her death in February 2011 had been caused by complications of ADEM. But an analysis of detailed hospital computer records shows the toddler died after her blood pressure was mismanaged – spiking when she was treated with steroids then allowed to fall too fast. Experts say this led to catastrophic brain damage. Although the detailed computer records were supplied to the coroner who carried out Jasmine’s inquest, crucial information concerning her blood pressure was not included in official medical records that should hold the patient’s entire clinical history. Dr Malcolm Coulthard, who specialises in child blood pressure and medical records examination, carried out the analysis of the files, comprising more than 350 pages of spreadsheets. Dr Stephen Playfor, a paediatric intensive care consultant, examined the computer records and came to the same conclusion as Dr Coulthard, that mismanagement of Jasmine’s blood pressure by Great Ormond Street and Lister Hospital, in Stevenage, was responsible for her death. Dr Coulthard told The Independent: “As a specialist paediatrician, it is with great regret and disappointment that I have concluded that the doctors' records in Jasmine Hughes’ medical notes fail to reflect the truth about her diagnosis and treatment.” Read full story Source: The Independent, 20 November 2020
  13. Content Article
    The Patient Safety Authority has put together information and tips for patients on a range of topics.
  14. Content Article
    This NHS Resolution video outlines the key components of good medical record keeping and highlights common mistakes to avoid.
  15. Event
    Free from the Patient Safety Movement offered for physicians, pharmacists, and nurses. This activity has been approved for AMA PRA Category 1 Credits™, ANCC contact hours, and ACPE contact hours. Registration
  16. News Article
    Matt Hancock has extended four national data sharing orders which allow GPs and NHS organisations to share confidential patient information, as part of the ongoing response to the COVID-19 pandemic. The data sharing instructions were initially put in place in March when the pandemic broke out in earnest, and they were due to expire at the end of September. Under the arrangement GPs, NHS providers, NHS Digital, NHS England/Improvement, local authorities and the UK Biobank can share information about patients’ treatment and medical history - if doing so would help their response to COVID-19. The data sharing instructions have now been extended until 31 March next year. According to the Department of Health and Social Care’s update which notified organisations of the extension, NHS entities can share information for reasons such as helping to support the NHS Test and Trace service, identifying further patients at risk of COVID-19, and understanding information about patient access to health and adult social care services. Read full story (paywalled) Source: HSJ, 20 August 2020
  17. Content Article
    It is hypothesized that 90% of antibiotic allergies documented in patients’ health records are not actual, potentially life threatening, type I allergies. This distinction is important because such documentation increases antibiotic resistance, as more second-choice and broad-spectrum antibiotics are then used. Evidence is lacking regarding causes of this inappropriate documentation. To develop interventions aimed at improving documentation, the authors of this study, published in the Annals of Family Medicine, explored experiences of family physicians and pharmacists in this area. They found that the professionals involved perceived that antibiotic allergy documentation is seldom accurate, which may contribute to development of antibiotic resistance, increased costs, and decreased patient safety.
  18. Content Article
    Providing patients with access to electronic health records (EHRs) may improve quality of care by providing patients with their personal health information, and involving them as key stakeholders in the self-management of their health and disease. With the widespread use of these digital solutions, there is a growing need to evaluate their impact, in order to better understand their risks and benefits, and to inform health policies that are both patient-centred and evidence-based. The main objective of this systematic review from Neves et al. was to assess the impact of these interventions on the six dimensions of quality of care. The findings suggest that providing patients with access to EHRs can improve patient safety and effectiveness
  19. Content Article
    Providing patients with access to electronic health records (EHRs) may improve quality of care by providing patients with their personal health information and involving them as key stakeholders in the self-management of their health and disease. With the widespread use of these digital solutions, there is a growing need to evaluate their impact, in order to better understand their risks and benefits and to inform health policies that are both patient-centred and evidence-based. The objective of this paper, published by BMJ Quality & Safety, was to evaluate the impact of sharing electronic health records (EHRs) with patients and map it across six domains of quality of care: patient-centredness effectiveness efficiency timeliness equity safety.
  20. News Article
    GPs will now be able to access records for patients registered at other practices during the coronavirus epidemic in a major relaxation of current rules. The move will allow appointments to be shared across practices, and NHS 111 staff will also have access to records to let them book direct appointments for patients at any GP practice or specialist centre. The change in policy has been initiated by NHS Digital and NHSX to enable swift and secure sharing of patient records across primary care during the covid-19 pandemic. It means that the GP Connect1 system, currently used by some practices to share records on a voluntary basis, will be switched on at all practices until the pandemic is over. In addition, extra information including significant medical history, reason for medication, and immunisations will be added to patients’ summary care records and made available to a wider group of healthcare professionals. Usually, individuals must opt in but following the changes only people who have opted out will be excluded. Read full story Source: The BMJ, 27 April 2020
  21. News Article
    MedStar Health launched a new tool that automatically calculates a patient's risk of having a heart attack or stroke within 10 years. The tool enables doctors to more easily show patients their personal risk for heart disease, stroke and other cardiovascular diseases over time using easy-to-read graphics. "Seeing their risk on a visual display is more powerful than me telling them their risk,” said Ankit Shah, Director, Sports and Performance Cardiology for the MedStar Heart & Vascular Institute at Union Memorial Hospital in Baltimore. The tool is embedded in MedStar's Cerner electronic health record (EHR), making it easier for physicians to use it during patient visits, health system officials said. The project highlights how MedStar Health National Center for Human Factors focuses on human factor design to improve technology for patients as well as providers. Final rules from the US Department of Health and Human Services (HHS) will make it easier in the future for patients to share their health data with third-party apps. Read full story Source: FierceHealthcare, 9 March 2020
  22. News Article
    Complaints about NHS care cannot always be investigated properly because of medical records going missing, the public services watchdog has said. Ombudsman Nick Bennett said many people were left "suspicious" and thought there was a "darker motivation". One woman whose notes went missing said she no longer trusted what doctors said and had lost faith in NHS transparency. The Welsh NHS Confederation said staff were "committed to the highest standards of care". In a report called Justice Mislaid: Lost Records and Lost Opportunities, Mr Bennett found 70% of 17 cases he looked at in Welsh NHS hospitals and care settings could not be properly investigated because of lost documents. Read full story Source: BBC News, 10 March
  23. Content Article
    Medication reconciliation (‘med rec’, as it is often called) refers to the ‘process of identifying the most accurate list of all medications a patient is taking … and using this list to provide correct medications for patients anywhere within the health system’. Two recent systematic reviews summarised the evidence for med rec interventions, finding that several med rec interventions reduced medication history errors and errors in patients’ admission and discharge medication regimens.
  24. News Article
    As part of the NHS Digital Child Health programme, Personal Child Health Records or “Redbook” will receive a digital makeover. NHS Digital has considered the limitations of the physical Redbook and decided that digitalisation is the way forward for parents to easily access important health and development information. Nurturey has been evolving its product to align with NHS' Digital Child Health programme. It aims to be an app that can make the digital Redbook vision a reality and currently in the process of completing all the necessary integrations and assurances. It is hoped that by using smart digital records, parents will be more aware of their child’s health information like weight, dental records, appointments and other developmental milestones. Tushar Srivastava, Founder and CEO of Nurturey, said: “Imagine receiving your child's immunisation alert/notification on the phone, clicking on it to book the immunisation appointment with the GP, and then being able to see all relevant immunisations details on the app itself. As a parent myself, I see the huge benefit of being able to manage my child’s health on my fingertips. We are working hard to deliver such powerful features to parents by this summer.” Read full story Source: National Health Executive, 5 February 2020
  25. Content Article
    NHS Digital are proposing to make changes in how private healthcare data is collected and with whom it is shared. This will involve trialling the suitability of existing NHS systems for the collection of private healthcare data and bringing it into line with the standards, processes and systems used for NHS funded care. These proposed changes are based on feedback the Acute Data Alignment Programme (ADAPt) programme has already received from a wide range of stakeholders. Wider insight from private and NHS healthcare providers, clinicians, the public and other key stakeholders is now welcomed as part of this consultation to ensure that we address any significant issues and concerns which could prevent the successful implementation of these changes. We expect this survey will take no more than 20 minutes to complete but will vary depending on the level of detail in your response.
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