Technology
consistently checked by staff during the undertaking of clinical tasks.
3. 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.
4. Concerns around confidentiality can prevent the display of critical patient information at bedsides that may be needed to support safe care, particularly in emergencies.
5. What and how critical patient information is displayed at the bedside varies across hospitals, with differences in positioning, visibility, readability and legibility.
6. 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).
7. 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.
8. 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.
9. 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.
10. 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.
11. 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.
12. 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.
13. 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.
14. 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.
Recommendations The report concludes with eight recommendations aimed at highlighting where the gaps are in the supporting staff to access the critical patient information they need and what can be done at national level to ensure there is improvement. The safety recommendations cover everything from design of computer systems and ward environments to future research around how best to make critical information visible and accessible: 1. The Office of the National Data Guardian should support local interpretation of the Caldicott Principles to give organisations and staff the confidence to display full patient names at the bedside to enable correct patient identification for safer care.
2. NHS England should develop 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) are available to clinical staff when accessing electronic patient record systems.
3. NHS England should provide 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).
4. NHS England, during a review of relevant Health Building Notes and Technical Memoranda, should include, as a consideration, that bedside patient information should be consistently visible.
5. NHS England should assess the priority, feasibility, and impact of future research into what and how critical information pertaining to the emergency care of patients in the
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