Technology
HSIB warns of lack of patient information at the bedside
NHS staff may not always be able to access accurate, critical information at the hospital bedside during life-threatening emergencies, a new report from the Healthcare Safety Investigation Branch has warned.
A new report from the Healthcare Safety Investigation Branch (HSIB) has warned that patient care is being hampered by a lack of critical information, prompting a call for action on a national scale. Access to digital systems, limitations of digital infrastructure, confidentiality concerns, issues with sharing information, how information is displayed at the bedside, and variation in practice 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. These safety issues became apparent as
HSIB undertook a national investigation into how critical information is accessed on a hospital ward, focusing on the CPR recommendation. The report emphasises that if incorrect information is accessed, the impact can be harmful and in the worst cases lead to death. This was seen in the case HSIB examined to illustrate the patient safety risks.
The reference case HSIB investigated the care of a Patient in a hospital who was found unresponsive in bed. A short time later he stopped breathing and his heart stopped. Help was immediately sought from the ward staff and a team gathered around the Patient’s bed. The team confirmed the Patient’s identity and noted that a decision had been made that he was not recommended to receive CPR if his heart stopped. CPR was not started. Around 10 minutes later a nurse who had previously been caring for the Patient returned from their break and recognised that the Patient had been misidentified as the patient in the next bed. The Patient whose heart had
stopped was recommended to receive CPR. CPR was immediately started, but despite this, the Patient died. HSIB 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, and the sharing of information among staff to support familiarity with their patients. A national investigation was undertaken to
explore the factors that affect the ability of staff to access critical patient information at
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. Nick Woodier, national investigator
the bedside. While the focus was on accessing someone’s CPR recommendation, findings may also be applicable to other forms of critical information. Findings related to patient identification will also be used as evidence for a future HSIB national learning report on ‘positive patient identification’. The investigation involved engagement with hospitals across England, experts in fields associated with human factors and the display of information, and national bodies with the remit of policy and strategy in the NHS.
Key challenges The final report sets out 14 findings giving a more detailed insight into the factors that make it challenging for staff to access the information they need. These include: 1. Clinical staff are not always able to access accurate, critical patient information at bedsides to support decision making in emergencies.
2. Patient identity wristbands are not March 2023 I
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