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Recommendations Better explanation of why ethnicity data is being collected. Develop better knowledge of links between ethnicity and health. Ensure ethnic categories reflect the current communities. Develop consistency in approach for recording ethnicity. A role for communities to contribute to how ethnicity is defined and categorised.- Posted
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- Health inequalities
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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.- Posted
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Key recommendations Positively engaging DSCR providers not currently on the assured provider list A standard to ensure the inclusion and consultation of end-users at every stage of the design, production, and implementation process of any new technology A new forum for social care providers, end users, and technology providers to discuss digital solutions for the sector A call for financial support for digital inclusion among people in receipt of adult social care services Mandatory digital training for staff- Posted
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HealthIT.Gov: SAFER guides (USA)
Patient Safety Learning posted an article in Health records and plans
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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- Posted
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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- Posted
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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- Posted
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Pregnant women should be asked how much they drink
Patient Safety Learning posted a news article in News
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- Posted
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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 -
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- Posted
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Brooke was admitted to Chadwick Lodge on 15 April 2019 and had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder; she initially failed to engage and was violent to staff and self-harming. By the middle of May 2019 she had made progress. On 5th June 2019 she was found with a ligature around her neck, which was suspended from the door of her room. Following this incident consideration should have been given to a formal risk assessment to include consideration of her level of observation. The details of the incident should have been fully disclosed to the MDT meeting on 6 June and consideration given to increasing the level of observation. The incident should also have been discussed and disclosed to all members of staff caring for her. On 10 June 2019 Brooke Martin was found secretly fiddling with a bedsheet on two occasions by two different members of staff.. The bedsheet should have been removed and examined, that would have shown that a section of the sheet had been torn off. This would and should have resulted in a full risk assessment and search of her room, that would have resulted in an increase in her level of observations to 1:1 observations. Brooke Martin, if constantly observed or other safety measures put in place would not have been able to tie the ligature that caused her death and would not therefore have died on 11t June 2019. Coroner's concerns During the course of the evidence it was explained to the coroner that it had not been possible to access the notes and records from an out of area hospital because not all the health providers were using “System One”. It is a major concern that the various systems used throughout the NHS are not compatible with each other and it is not always possible for each healthcare provider to access the notes and records of the patient. This situation should be reviewed to see how access across the NHS can be gained to patient records when required. The coroner was told by one senior clinician that when a patient is referred to his specialist mental health unit it is often the case, that is 9 times out of 10, he does not receive all the information of the patient’s history. This would not be the case if he had direct access to the records.- 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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This blog explains the benefits of enabling people to access their health records within primary care.- Posted
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How to access your health records
Claire Cox posted an article in GP records
What will I learn? How to access your GP record How to access your summary care record How to access someone else's care record How to get your records changed -
Content Article
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.