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Showing results for tags 'Care record'.
Found 68 results
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Content ArticleDoctors and nurses must adapt their routines and improvise their actions to ensure continued patient safety, and for their roles to be effective and to matter as new technology disrupts their working practices. Research from Lancaster University Management School on the use of a computerised physcian order entry system in a hospital in Saudi Arabia, published in the Journal of Information Technology, found electronic patient records brought in to streamline and improve work caused changes in the division of labour and the expected roles of both physicians and nursing staff. These changes saw disrupted working practices, professional boundaries and professional identities, often requiring complex renegotiations to re-establish these, in order to deliver safe patient care. Managers implementing these systems are often quite unaware of the unintended consequences in their drive for efficiency.
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Content Article
Royal Pharmaceutical Society: Ward round checklist example
Claire Cox posted an article in Handover
Ward rounds happen each day with your clinical team. In order for them to standardise the way they are conducted East Lancashire Hospital NHS Trust has designed a ward round check list, this is to ensure that everyone gets the same safety checks and important discussions are had for every patient. -
Content ArticleOur experience of attending the Patient Safety Learning Annual Conference and entering our patient safety initiative into the awards.
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Content ArticleImperial College Healthcare NHS Trust maternity service provides care for around 10,000 babies and their mothers each year throughout pregnancy, labour, and the postnatal period. The Trust introduced the Cerner electronic patient record system including a maternity module for clinical documentation in 2014. Contractions and foetal and maternal heart rate are monitored using cardiotocograph (CTG) devices. Previously, the readings were printed out on rolls of paper. Midwives added handwritten clinical observations to these ‘foetal strips’ and used them to make critical decisions about the management of labour. These paper records were hard to share to quickly get a second opinion. They were prone to fading over time so did not always provide a permanent record and they were not integrated into the electronic patient records for our patients.
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Content ArticleThe North West London Integration Toolkit is intended to support communities, people and partners as they work towards the shared vision of integrated care. The toolkit is the culmination of over 200 individuals and organisations across North West London coming together to share knowledge and develop ideas as to how to implement whole systems integrated care. The toolkit is a living document and repository of collective learnings. It will evolve and be updated as local areas start to implement their plans and lessons are learned and shared.
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Content ArticleElectronic health records (EHR) can improve safety via computerised physician order entry with clinical decision support, designed in part to alert providers and prevent potential adverse drug events at entry and before they reach the patient. However, early evidence suggested performance at preventing adverse drug events was mixed. In this study published in BMJ Quality & Safety, Bates et al. used data from 1527 hospitals in the USA from 2009 to 2016 who took a safety performance assessment test using simulated medication orders to test how well their EHR prevented medication errors with potential for patient harm. Results found that the average hospital EHR system correctly prevented only 54.0% of potential adverse drug events tested on the 44-order safety performance assessment in 2009; this rose to 61.6% in 2016. Hospitals that took the assessment multiple times performed better in subsequent years than those taking the test the first time, from 55.2% in the first year of test experience to 70.3% in the eighth, suggesting efforts to participate in voluntary self-assessment and improvement may be helpful in improving medication safety performance. The authors conclude that medication order safety performance has improved over time but is far from perfect. The specifics of EHR medication safety implementation and improvement play a key role in realising the benefits of computerising prescribing, as organisations have substantial latitude in terms of what they implement. Intentional quality improvement efforts appear to be a critical part of high safety performance and may indicate the importance of a culture of safety.
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Content ArticleThis commentary, published in the Journal of the American Medical Informatics Association (JAMIA), highlights the value of explicit inclusion of context in Electronic Health Records (EHRs). The author highlights how discussions of why decisions were made illustrate important relationships in elements of patient care than can often get lost in clinical notes.
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Content Article
Patient allergies and electronic health records
Claire Cox posted an article in Allergies
This case study written by Matthew Doyle and published by PSNet, Agency for Healthcare Research and Quality, describes a case of a patient in the US who was given a drug they were allergic to, the implications of this and how to mitigate future events. -
Content ArticleThis joint statement from the Health Research Authority and the Medicines and Healthcare products Regulatory Agency, supported and endorsed by the Devolved Administrations, sets out the legal and ethical requirements for seeking and documenting consent using electronic methods. This statement is aimed at electronic signatures obtained for clinical trials.
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Content ArticleIn this blog, Dr Amir Hannan, GP, describes how it’s normal for patients to access their electronic health records and easy for them to understand them at Haughton Thornley Medical Centres.
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Content Article
How to access your health records
Claire Cox posted an article in GP records
There are a number of different types of health record, accessing them is free, and healthcare professionals have a legal requirement to allow you to see them. -
Content Article
This is Me - My care passport
Claire Cox posted an article in Care plans
Based on a previous ‘Hospital Passport’ this version is designed to be used by everyone within a variety of care settings. The content was developed together by Surrey and Borders Partnership NHS Foundation Trust Acute Liaison, Specialist Therapies and Older Adults services, Royal Surrey County Hospital and the Surrey Alzheimer’s Association. -
Content ArticleProviding 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.
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Content Article
The problem with medication reconciliation
Claire Cox posted an article in Medication including labelling
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. -
Content ArticleNHS 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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Content ArticleIn this powerful blog, the author draws upon personal experience and insight to explain why she campaigns for carers and patients to have access to their own health records, and the difference this would make to patient safety. "Despite continued promises of access to all our health information by successive politicians and the talk of new gateways to our health information linking primary, secondary and social care, to people like us it seems as far away as ever. We hear about the Empowering the Person initiative, projects to improve data flows, data standards and all those new Apps but citizens like us are still as helpless as ever standing next to that stretcher in A/E without the very basic information to save our loved one’s life in a crisis."
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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 ArticleThis 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.
