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Showing results for tags 'Care record'.
Found 68 results
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News Article
Newly installed EPR contributed to A&E death, warns coroner
Patient Safety Learning posted a news article in News
A newly installed electronic patient record contributed to the “preventable” death of a 31-year-old woman in an emergency department, a trust has been warned. Emily Harkleroad died at University Hospital of North Durham in December 2022 following “failures to provide [her] with appropriate and timely treatment” for a pulmonary embolism, a coroner has said. The inquest into her death heard emergency clinicians had raised concerns about a newly installed electronic patient record, provided by Oracle Cerner, which they said did not have an escalation function which could clearly and quickly identify the most critical patients. The inquest heard the new EPR, installed in October 2022, did not have a “RAG rating” system in which information on patient acuity “was easily identifiable by looking at a single page on a display screen” – as was the case with the previous IT system. The software instead relied on symbols next to patients’ names which indicate their level of acuity when clicked on, but did “not [provide] a clear indication at first glance” of their level of acuity. Rebecca Sutton, assistant coroner for County Durham and Darlington, said that “errors and delays” meant Ms Harkleroad did not receive the anticoagulant treatment that she needed and “which would, on a balance of probabilities, have prevented her death”. “It is my view that, especially in times of extreme pressure on the emergency department, a quick and clear way of identifying the most critically ill patients is an important tool that could prevent future deaths.” Read full story (paywalled) Source: HSJ, 23 February 2024 -
Content ArticleOn 18 December 2022, Emily Harkleroad collapsed when out with a friend. She was taken by ambulance to the University Hospital of North Durham Emergency Department. Despite staff recognising that pulmonary embolism was the likely diagnosis, there were failures to provide Emily with appropriate and timely treatment for pulmonary embolism. Errors and delays in the Emily’s medical treatment resulted in her not receiving the anticoagulant treatment that she needed, and which would, on a balance of probabilities, have prevented her death. She died as a result of pulmonary embolism in the early hours of 19 December 2022 at the University Hospital of North Durham.
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Content ArticleExpecting paramedics to wade through shared care records is unsafe and inefficient. In an emergency, access to essential information has to be easy and fast, writes Claire Jones from NHS England South West. Whilst ambulance services may need access to the entire longitudinal record, it is imperative that in those first vital minutes of an emergency they have the most pertinent and relevant data at their fingertips. In such cases, information sharing can be a matter of life or death. We should make it as easy as possible for emergency care providers to access and view relevant information about the person in their care.
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News Article
NHSE warns widely used EPR could pose ‘serious risks to patient safety’
Patient Safety Learning posted a news article in News
NHS England has issued a national alert to all trusts providing maternity services after faults were discovered in IT software that could pose “potential serious risks to patient safety”. According to the alert, the Euroking electronic patient record provided by Magentus Software could be displaying incorrect patient information to clinicians. The Euroking EPR is used in the maternity departments of at least 15 trusts according to information held by HSJ. These organisations have been asked to “consider if Euroking meets their maternity service’s needs” and to “ensure their local configuration is safe”. Trusts with different maternity EPR providers have also been asked to reassess the clinical safety of their solutions. The potential “serious risks” relate to a fault in the Euroking EPR which allows new patient information to overwrite previously recorded information, which could lead to “incorrect management of the pregnancy and subsequent harm”. Read full story (paywalled) Source: HSJ, 8 December 2023 -
Content ArticlePotential serious risks to patient safety have been identified with the use of Magentus Software Limited’s Euroking maternity information system. These concern specific data fields: certain new patient information, recorded during a patient contact, can overwrite ('back copy') information previously recorded in the patient’s pregnancy record. certain pregnancy-level data (information relevant only to a specific pregnancy event) can be saved at a patient level (where information relevant throughout a person's life is recorded), causing new information to overwrite (‘back copy’) previously recorded data across an entire patient record. certain recorded pregnancy-level data can pre-populate into new pregnancy records (‘forward copy’), which can mean clinicians will see incorrect patient information, and attempts to correct this can result in the issue described at (ii) above.
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Content ArticleBetween 2009 and 2010, 48 year-old David Richards was admitted to intensive care during the ‘swine flu pandemic’. He spent six weeks in an intensive care unit (ICU), first on mechanical ventilation and later receiving extra-corporeal membrane oxygenation (ECMO) treatment. He recovered and became a survivor of severe acute respiratory distress syndrome (ARDS). During his 50 days in intensive care, David's former partner Rose kept an ‘ICU diary’. Rose recorded clinical updates as well as conversations with relatives and staff who were by David's bedside. In this article, David describes how important this diary has been to him understanding and processing his experience. It forms a record not just of procedures, treatments and clinical signs but of how he reacted, how he appeared to feel and how he tried to communicate during a time that were permeated by delirium.
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Content ArticleFor many years the NHS has talked about the need to shift to a more personalised approach to health and care—where people have choice and control over the way their care is planned and delivered, based on “what matters” to them and their individual strengths, needs and preferences. In this HSJ article, Ben Wilson, product solution director at Orion Health, discusses the progress, benefits and future possibilities for an integrated, patient-centric healthcare system.
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News Article
Trust told it ‘lacks skills or integrity’ to carry out suicides review
Patient Safety Learning posted a news article in News
A senior clinician has raised fundamental concerns about a trust’s probe into dozens of suicide cases, which was sparked by his allegations that staff had tampered with the notes of a patient. Cambridgeshire and Peterborough Foundation Trust announced in July there would be an internal review of 60 suicide cases dating back to 2017. But a key whistleblower told HSJ he fears it could be a “whitewash” and it should be carried by an external, independent investigator rather than led by the trust. The suicides review was prompted by allegations staff had added a care plan into the patient record of Charles Ndhlovu, a day after the 33-year-old had died by suicide in 2017. The allegations, not contested by the trust, were based on the findings of an internal investigation in 2021 of the trust’s conduct around Mr Ndhlovu’s case. Read full story (paywalled) Source: HSJ, 6 September 2023 -
Content ArticleMaking data on medical interventions easier to collect and collate would increase the odds of spotting patterns of harm, according to the panel of a recent HSJ webinar. When Baroness Julia Cumberlege was asked to review the avoidable harm caused by two medicines and one medical device, she encountered no shortage of data. “We found that the NHS is awash with data, but it’s very fractured,” says Baroness Cumberlege, who chaired the Independent Medicines and Medical Devices Safety Review and now co-chairs the All-Party Parliamentary Group which raises awareness of and support for its findings. It was a challenge on which Professor Sir Terence Stephenson had cause to deeply reflect back in 2014. That was the year in which he was asked to chair an independent review of medical devices, following concerns about the safety of metal-on-metal hip replacements and PIP silicone breast implants. “The NHS stepped up to the plate really quickly and said: ‘Even if it’s a private hospital that put this in, we will take it out to protect your safety,’” recalled Sir Terence, now Nuffield professor of child health at Great Ormond Street Institute of Child Health and chair of the Health Research Authority for England. “But the big problem was they couldn’t identify who had which implants. No doubt somebody somewhere had written this down with a fountain pen and then someone spilt the tea over it and the unique information was lost.”
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Maureen discusses the important role of professional standards in building a patient safety infrastructure, the need to reframe safety as a positive idea and her experience of implementing learning processes during her time as a GP. -
Content ArticleHindsight bias (colloquially known as ‘the retrospectoscope’) is the tendency to perceive past events as more predictable than they actually were. It has been shown to play a significant role in the evaluation of an past event, and has been demonstrated in both medical and judicial settings. This study in Clinical Medicine aimed to determine whether hindsight bias impacts on retrospective case note review, through an internet survey completed by doctors of different grades. The authors found that in some cases, doctors are markedly more critical of identical healthcare when a patient dies compared to when a patient survives. Hindsight bias while reviewing care when a patient survives might prevent identification of learning arising from errors. They also suggest that hindsight bias combined with a legal duty of candour will cause families to be informed that patients died because of healthcare error when this is not a fact.
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Content ArticleThis tool from the Parkinson's Association of Ireland allows people with Parkinson's to record their essential medical information in an easy to access format, should they need assistance or medical treatment. It includes: information about the physical symptoms of Parkinson's, including how it affects speech and movement. instructions on how to interact with the person if they are having difficulty communicating. personal details and emergency contacts details of medications and treatments the person is taking.
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Content ArticleIncomplete or inaccurate recording of ethnicity will undermine attempts to address health inequalities and improve access, experience and outcomes for Black, Asian and minority ethnic communities. This report by the Race Equality Foundation and the Office for National Statistics (ONS) looks at different aspects of the recording of ethnicity in healthcare. The authors interviewed people from a range of communities across England, as well as healthcare workers from different areas and settings to understand both sides of the process of collecting ethnicity data.
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Content ArticleThis 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.
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Content ArticleDigital transformation across adult social care is occurring rapidly, however, uptake is not uniform, and the care sector is yet to fully harness digital tools to transform care delivery. With unprecedented service pressure and demand across health and care services, using digital tools in care settings has the potential to relieve some pressure by increasing efficiency and better supporting the workforce. This report by the think tank Public Policy Projects brings together the thoughts and ideas of many Adult Social Care experts regarding the future of the care sector, and the opportunities which digital advancements can bring. Chaired by Damian Green MP, it is intended as a thought-piece to guide action and further work on the area, as a guideline for future development.
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Content ArticleThis article tells the story of Mr K, who died following a misdiagnosis of tension pneumothorax. Mr K was 81 and had a history of chronic obstructive pulmonary disease (COPD) and bullous emphysema. He had been diagnosed with a bulla, a large air pocket, in his right lung. The medical team treating Mr K after his admission to hospital with shortness of breath failed to review his previous x-ray and medical notes, and did not involve the respiratory team in his treatment. This led to his misdiagnosis, after which he was fitted with an unnecessary chest drain. The drain collapsed the bulla and ruptured a blood vessel leading to progressive bleeding. The medical team did not recognise their error or Mr K's bleeding and he died two days following the insertion of the drain. At his inquest, the Coroner found that the unnecessary chest drain led to Mr K's death, and that there was a missed opportunity to reassess the situation at a review the next day. They ordered that a prevention of future death report be made as the evidence heard at the inquest revealed a number of matters that gave rise to concern.
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Content Article
HealthIT.Gov: SAFER guides (USA)
Patient Safety Learning posted an article in Health records and plans
The SAFER Guides consist of nine guides organiaed into three broad groups. These guides enable healthcare organisations to address electronic health record (EHR) safety in a variety of areas. Most organisations will want to start with the Foundational Guides, and proceed from there to address their areas of greatest interest or concern. -
Content ArticlePoor and ambiguous medication recording is a common issue identified by the Care Inspectorate during inspections or complaints activity. This guidance aims to support care staff working in residential care services who record medication administration and develop personal plans, by giving common sense guidance on medication recording and personal plans.
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News Article
NHS doctors' paperwork piles up after cyber-attack
Patient Safety Learning posted a news article in News
Doctors say it could take months to process mounting piles of medical paperwork caused by a continuing cyber-attack on an NHS supplier. One out-of-hours GP says patient care is being badly affected as staff enter a fourth week of taking care notes with pen and paper. The ransomware attack against software and services provider Advanced was first spotted on 4 August. The company says it may take another 12 weeks to get some services back online. Dr Fay Wilson, who manages an urgent-care centre in the West Midlands, says the main choke point for her team is with patient records. She said it could affect patient care "because we can't send notifications to GP practices, except by methods that don't work because they require a lot of manual handling, and we haven't got the staff to actually do the manual handling". Read full story Source: BBC News, 31 August 2022 -
Content ArticleThis study in JAMA Network Open aimed to investigate how often patients who read open ambulatory visit notes perceive mistakes, and what types of mistakes they report. The results of the study showed that: 1 in 5 patients who read a note reported finding a mistake 40% perceived the mistake as serious the most common mistakes reported were mistakes in diagnoses, medical history, medications, physical examination, test results, notes on the wrong patient and sidedness. The authors suggest that patients may perceive important errors in their visit notes, and inviting them to report mistakes may be associated with improved record accuracy and patient engagement in safety.
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News Article
Cyber attack: NHS staff unable to access patient notes for three weeks
Patient Safety Learning posted a news article in News
A cyber attack that has caused a major outage of NHS IT systems is expected to last for more than three weeks, leaving doctors unable to see patients’ notes, The Independent has learned. Mental health trusts across the country will be left unable to access patient notes for weeks, and possibly months. Oxford Health Foundation Trust has declared a critical incident over the outage, which is believed to affect dozens of trusts, and has told staff it is putting emergency plans in place. One NHS trust chief said the situation could possibly last for “months” with several mental health trusts, and there was concern among leaders that the problem is not being prioritised. In an email to staff, Oxford Health Foundation Trust chief executive Nick Broughton, said: “The cyber attack targeted systems used to refer patients for care, including ambulances being dispatched, out-of-hours appointment bookings, triage, out-of-hours care, emergency prescriptions and safety alerts. It also targeted the finance system used by the Trust." The NHS director said: “The whole thing is down. It’s really alarming…we’re carrying a lot of risk as a result of it because you can’t get records and details of assessments, prescribing, key observations, medical mental health act observations. You can’t see any of it…Staff are going to have to write everything down and input it later.” They added: “There is increased risk to patients. We’re finding hard to discharge people, for example to housing providers, because we can’t access records.” Read full story Source: The Independent, 11 August 2022 -
Content ArticleThis strategy sets out the Secretary of State for Health and Social Care’s vision for how data will be used to improve the health and care of the population in a safe, trusted and transparent way. It: provides an overarching narrative and action plan to address the current cultural, behavioural and structural barriers in the system, with the ultimate goal of having a health and care system that is underpinned by high-quality and readily available data marks the next steps of the discussion about how we can best utilise data for the benefit of patients, service users, and the health and care system This strategy applies to England only. The strategy shows how data will be used to bring benefits to all parts of health and social care – from patients and care users to staff on the frontline and pioneers driving the most cutting-edge research. It is backed by a series of concrete commitments, including: investing in secure data environments to power life-saving research and treatments using technology to allow staff to spend more quality time with patients giving people better access to their own data through shared care records and the NHS App.
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News Article
‘Total IT failure’ at four hospitals sparks safety concerns
Patient Safety Learning posted a news article in News
Four hospitals in Greater Manchester are struggling with a near ‘total IT failure’ which has forced staff in all key services to use handwritten lists and notes. The problems have affected multiple IT systems across Royal Oldham, Fairfield General, Rochdale Infirmary and North Manchester General hospitals. Staff at the sites are running theatre and emergency departments using handwritten patient lists and notes, while bloods and scan results are also being written by hand. Patient histories are largely unavailable. HSJ spoke to staff who said there are major concerns over patient safety, as the lack of digital systems increases the risk of errors, and also slows down multiple processes. They described the problems as a “total IT failure”. Chris Brookes, deputy CEO and chief medical officer, said: “Patient safety and maintaining essential services remains our priority. We are doing everything we can to fix the IT issues and to limit disruption to patients and our services." Read full story (paywalled) Source: HSJ, 25 May 2022 -
Content ArticleThis report published by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) looked to identify and explore remediable factors in the clinical and organisation of the physical healthcare provided to adult patients admitted to a mental health inpatient setting. The report suggests that a physical healthcare plan should be developed when patients are admitted to a mental health inpatient setting. Other key messages aimed at improving care include calls to: formalise clinical networks/pathways between mental health and physical health care; involve patients and their carers in their physical health care, and use admission as an opportunity to assess and involve patients in their general health, and include mental health and physical health conditions on electronic patient records.
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Content ArticleThe following questionnaire will take about 8 minutes to complete and is designed to explore your professional experience of using the electronic patient record (EPR) system(s) where you work. By participating in this research, you will help the NHS understand how your EPR system is working for you, including where it is performing well and where more can be done to enhance your experience.
