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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- Posted
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Hancock extends emergency patient data sharing rules
Patient Safety Learning posted a news article in News
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 -
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NHS e-health systems 'risk patient safety'
Patient Safety Learning posted a news article in News
Hospitals across England are using 21 separate electronic systems to record patient health care – risking patient safety, researchers suggest. A team at Imperial College say the systems cannot "talk" to each other, making cross-referencing difficult and potentially leading to "errors". Of 121 million patient interactions, there were 11 million where information from a previous visit was inaccessible. The team from London's Imperial College's Institute of Global Health Innovation (IGHI) looked at data from 152 acute hospital trusts in England, focusing on the use of electronic medical records on the ward. Around a quarter were still using paper records. Half of trusts using electronic medical records were using one of three systems: researchers say at least these three should be able to share information. 10% were using multiple systems within the same hospital. Writing in the journal BMJ Open, the researchers say: "We have shown that millions of patients transition between different acute NHS hospitals each year. These hospitals use several different health record systems and there is minimal coordination of health record systems between the hospitals that most commonly share the care of patients." Lord Ara Darzi, lead author and co-director of the IGHI, said: "It is vital that policy-makers act with urgency to unify fragmented systems and promote better data-sharing in areas where it is needed most – or risk the safety of patients." A spokesperson for NHSX, which looks after digital services in the NHS, said: "NHSX is setting standards, so hospital and general practioner IT systems talk to each other and quickly share information, like X-ray results, to improve patient care." Read research article Read full story Souce: BBC News, 5 December 2019- Posted
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Royal Pharmaceutical Society: Ward round checklist example
Claire Cox posted an article in Handover
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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- Posted
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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- Posted
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NHS to benefit from digital 'Redbook' app
Patient Safety Learning posted a news article in News
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- Posted
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This is Me - My care passport
Claire Cox posted an article in Care plans
This booklet is for patients to download and use. It includes: My basic information Things you must know about me Things that are important to me My likes and dislikes This passport can be taken into any healthcare setting. -
Content Article
This blog explains the benefits of enabling people to access their health records within primary care.- Posted
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Patient allergies and electronic health records
Claire Cox posted an article in Allergies
Key take home messages A patient's drug allergy status should be checked and updated at all patient contacts with healthcare professionals. Recording suspected drug allergy in the patient record requires a minimum degree of detail including the reaction, the drug given, the time-frame of the reaction from initiation of the drug, and what drugs or drug groups to avoid. Both adverse drug reactions and drug allergies should be documented in the electronic patient record, separately if possible but together if not, and should not be removed from the record without consideration of and the involvement from the patient in the decision to remove it. Drug allergy status should be recorded on all written communication regarding the patient between health care professionals.- Posted
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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- Posted
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We have a new app within Homerton which is featured on the hub. The Homerton University Hospital (HUH) Action Card App is an initiative that aims to bridge the gap between information/processes with clinical members of staff without the need to log into a computer, access the intranet, and finding the long black and white document which is never ending. The Action Card App has easy to read, 1-page coloured documents relating to local and national/local incident trends and Never Events. We entered the Patient Safety Learning Awards on the back of seeing the hub and finding content on there that was incredibly useful on a day to day basis. We genuinely weren't expecting to hear anything back from the Patient Safety Learning team as we are a small trust that not a lot of people know about, and we thought the standard of patient safety initiatives would be high, with many trusts miles ahead of us. I have to say, the team at Patient Safety Learning were nothing but lovely, from the moment the conversation started about the prospect of entering the awards. They all took the time for correspondence and they treated you as a person, as oppose to an entry. When we got the information that we had won the overall prize, we were gobsmacked and elated. The app team were overjoyed with the sense that our hard work had paid off and someone had taken the time to appreciate the work we have been doing at Homerton. We were asked to prepare a presentation prior to the awards, which showcased our work and to share with the attendees of the conference. The day arrived, with so much great work, inspiring talks and a general atmosphere of wanting to do more to keep our patients safe. I would like to thank everyone who heard our presentation (some may say performance) and thank everyone in the Patient Safety Learning team for their help with this process.- Posted
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