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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.

Based on initial system requirements, Williams et al. designed the dashboard’s user interface over three iterations with six GPs, seven pharmacists and a member of the public. Prescribing safety indicators from previous work were implemented in the dashboard. Pharmacists were trained to use the intervention and deliver it to general practices. A web-based electronic dashboard was developed and linked to shared care records in Salford, UK. The completed dashboard was deployed in all but one (general practices in the region. By November 2017, 36 pharmacists had been trained in delivering the intervention to practices. There were 135 registered users of the dashboard, with an average of 91 user sessions a week. The authors have developed and successfully rolled out of a complex, pharmacist-led dashboard intervention in Salford, UK. System usage statistics indicate broad and sustained uptake of the intervention. The use of systems that provide regularly updated audit information may be an important contributor towards medication safety in primary care.

Safety observation It may be beneficial for NHS care providers to explore options for the translation of written appointment communications, including pre-attendance guidance, for patients whose preferred written language is not English.

Thank you to everyone who has shared your powerful stories with me about your own experiences and those of family members. Your testimonies are both heartfelt and heart breaking, a very emotional read. I cannot think of a greater motivation for decision makers to do what is right, without delay. I was very privileged to meet Yasmin Golding and to hear about the #SaferMumSaferBaby campaign by the Epilepsy Society. It was humbling to hear directly from Yasmin about her hopes and fears for the future and why having information to help minimise risk would make the world of difference. Thank you Yasmin 🙏 It’s so vital that patients can get the right information about medicines to be able to make the decisions which are the safest for themselves and their families. I met with Mid and South Essex Integrated Care System and Karen Flitton for a World Patient Safety Day webinar. The theme was Medication Without Harm and it was wonderful to see so many people with a passion for patient safety. I was also very pleased to meet with the team at Healthcare Safety Investigation Branch for a morning webinar to talk about patient safety and inclusion. Thanks very much James Titcombe for the kind invitation and to everyone for your insightful questions. Patient safety in a world of ransomware attacks was part of my conversation with Nicola Byrne the National Data Guardian. With more electronic patient records and electronic prescribing, there is a risk that patients can be harmed when we don’t have timely access to information. Cyber security is key to keeping patients safe by ensuring that access to information is protected. The Speak Up Month podcast I recorded with Jayne Chidgey-Clark and the National Guardian's Office has a theme of speaking up for safety and why psychological safety is so important Listen here: https://lnkd.in/enBsUx7w Psychological safety for all was also a topic of conversation when I met with Professional Standards Authority CEO Alan Clamp. Their recent publication Safer Care for All highlights the need for a swift and coordinated system response which tackles inequalities. We can only get this right if we get it right for everyone. Such a thought provoking week- thank you to everyone who has been in touch to help me have a greater understanding about your concerns and what needs to be done to get this right. *This article was first published on LinkedIn.