Barriers to accessing patient information during emergency situations are a significant safety risk in the NHS, which could lead to otherwise preventable poor outcomes or even death, a health safety watchdog has warned.
In its latest national investigation report, published today, the Healthcare Safety Investigation Branch (HSIB) found that NHS staff may not always be able to access accurate, critical information at the hospital bedside during life-threatening emergencies.
Difficulties accessing digital systems, confidentiality concerns, information sharing issues, disparities in how information is displayed at the bedside, and other variations in information practices are just some of the barriers cited in the report to staff being able to provide the most effective emergency care to patients at their bedside.
The report makes a number of national recommendations, which focus on standardising patient information practices and making key information easier to access at the bedside. Key information includes patient identity and whether attempts at resuscitation are recommended in the event of a cardiac arrest.
The HSIB undertook a national investigation into how critical information is accessed on a hospital ward, following a case where an elderly hospital patient died following confusion over his data. The patient, a 79-year-old man, experienced cardiac arrest but CPR was not started as he was misidentified as the patient in the next bed, who had a recommendation not to receive CPR. The mix-up was spotted a short time later when the nurse who had been caring for the unresponsive patient came back from a break and realised it was the wrong patient. CPR was then commenced but sadly the patient died.
The HSIB's investigation identified key factors that contributed to the reference event, including access to computer systems, the display of information around the bed, and the sharing of information among staff to support familiarity with their patients.
Key National Investigation Findings
The HSIB report sets out 14 findings into national factors which make it challenging for hospital staff to access the information they need, including:
- What and how critical patient information is displayed at the bedside varies across hospitals, with differences in positioning, visibility, readability, and legibility.
- Concerns around confidentiality can limit display of patient identifiers at bedsides that may be needed to support safe care, particularly in emergencies.
- Patient identity wristbands are not consistently checked during the undertaking of clinical tasks.
- 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.
- 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 may not provide the information staff need to care for their patients because of where and how they are undertaken.
- 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.
- 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.
Recommendations to Improve Care
The report concludes with eight national recommendations and three safety observations. The recommendations cover everything from better design of computer systems and electronic health care records and ward environments, improved guidance on nursing handovers, to future research around how best to make critical patient information always visible and accessible to staff.
Commenting on the investigation, HSIB National Investigator Nick Woodier said: "Our reference case was a distressing reminder of what can happen when treatment is delayed because staff are not able to easily see the critical information they need in an urgent situation. Across the investigation we heard about multiple contributing factors that can have an impact – from poor lighting to the variation in CPR recommendation words and symbols – when clinical staff are having to make quick decisions in pressured and fraught environments.
"What became clear to us is that a number of recommendations were needed to ensure the many gaps and safety issues our investigation found are addressed. National organisations should be ensuring the accessibility and visibility of information, so that staff can provide the best levels of care to patients at the bedside, many of whom could be in a critical condition and may need life-saving treatment."
In relation to confidentiality concerns, Dr Nicola Byrne, National Data Guardian for Health and Social Care, commented on the findings and recommendations: “Providing patients' names at their bedsides so they can be correctly identified is essential for safe care. Caldicott Principle 7, which advises that ‘the duty to share information for individual care is as important as the duty to protect patient confidentiality’, should be interpreted locally to permit this.”