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Written on 6th February 2023 by Richard Money-Kyrle

Healthcare watchdog, HSIB, has published the findings of its national investigation, Access to critical patient information at the bedside.

HSIB’s findings and recommendations highlight the risks to patient safety when healthcare staff at the patient’s bedside cannot quickly and accurately access information that is needed to provide patients with emergency care. The report focussed on how patients are identified and life-changing decisions made about whether to give them cardiopulmonary resuscitation (CPR) after cardiac arrest.

This is one of the last remaining national investigations that will be reported by HSIB before it changes its name and status, and takes on increased powers, including safe space investigations, in April 2023 as HSSIB

The patient’s experience – HSIB’s reference event

HSIB’s national investigation was prompted by mistakes in the identification and treatment of a patient in hospital after he suffered a cardiac arrest. The patient was found unresponsive in his bed on the ward and then stopped breathing and suffered a cardiac arrest. The healthcare team who were called to the emergency incorrectly identified him as the patient (with the same first name) who was in the next bed and whose   medical notes recorded that he was not to be given CPR if his heart stopped from a cardiac arrest. As a result of the mistake, the unresponsive patient was not given CPR until ten minutes later, when the only nurse on the ward who knew him returned from a break and spotted the mistake. CPR was started but the patient died.

The hospital staff told HSIB that in this emergency situation nobody had looked at the patient’s identity wristband. They had simply trusted that other staff members had identified the patient. The hospital trust had a policy which listed situations in which a patient should be formally identified, but their policy did not say what to do in an emergency or specify whether/how to identify a patient with cardiac arrest. Staff knew to check their patients’ wristbands when giving medication or taking the patient to the operating theatre but did not consider doing so routinely or in an emergency. Staff had not had any training on the patient identification policy or on formal identification of patients.

HSIB found inconsistency in the placement of whiteboards near patients’ beds and the information they contained. Staff had not been trained in what to write on the boards, and their ability to read them was affected by lighting, curtains, equipment and legibility. Instructions not to attempt CPR (DNACPR) on a patient were recorded in various places, including on the electronic patient record. HSIB found that the nursing handover sheet, which was the most accessible source of critical patient information at the bedside, was sometimes inaccurate and not a reliable source. Staff used handheld devices and barcode technology at the bedside but these did not give information on CPR recommendations.

HSIB found that the patient’s treatment had been delayed by misidentification and limited bedside access to critical information about him.

HSIB’s findings from the national investigation

Errors in patient care following misidentification of patients are a known cause of avoidable injury. HSIB previously reported on surgical errors arising from incorrect patient identification in outpatient settings. HSIB’s latest national investigation looks at misidentification of inpatients (staying in hospital). Specifically, the report focusses on the risks to inpatient  safety from healthcare staff being unable to access critical information, including their identity and CPR treatment recommendations, to provide appropriate care in emergency situations. 

HSIB’s findings during the national investigation included:

  • Patient identity wristbands are not consistently checked by staff whilst carrying out clinical tasks.
  • Staff cannot always identify patients in an emergency and access critical information about their care owing to limitations of technology and the working environment.
  • There is no national guidance to support consistency and visibility of critical patient information, whether on high-tech (digital) or low-tech (whiteboards/posters) displays. In practise, hospitals differ in the way they display critical patient information at the bedside and the content of information displayed, with difficulties arising from lighting, positioning, visibility, readability and legibility. In some cases, concerns about confidentiality are preventing vital information from being displayed that may be needed to support safe care, particularly in emergency situations.
  • Healthcare staff find it difficult to access digital systems because of limited or poorly functioning hardware, or don’t know which of many different digital systems contain the information they need. This leads to them having to use less reliable, paper-based systems to access important patient information.
  • Different words and symbols are used to indicate CPR recommendations, leading to safety risks for patients when CPR recommendations are not understood and mistakes in emergency care for patients with cardiac arrest.
  • There is no national guidance on the best way to carry out nursing handovers of care and staff do not always receive the necessary information to provide safe care. However,  implementation of electronic handover systems in clinical workplaces is currently limited by digital infrastructure and systems that do not meet the needs of their users.

HSIB made eight safety recommendations in relation to guidance, research and standardisation of bedside accessible patient information to help hospitals ensure that healthcare staff can access the vital information they need to provide patients in emergency situations with correct and appropriate care.

If you have been seriously injured as a result of medical negligence, or have been contacted by HSIB/HSSIB, MNSI or NHS Resolution following your hospital care, you can speak to one of our experienced solicitors, free and confidentially, for advice on how to respond or make a claim, by contacting us here.