NHS staff may not always be able to access accurate, critical information at the hospital bedside during life-threatening emergencies, the Healthcare Safety Investigation Branch (HSIB) has warned in its latest report.
Access to digital systems, limitations of digital infrastructure, confidentiality concerns, issues of 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 patient, a 79-year-old man’s heart stopped 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 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. This included:
- 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.
- 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.
- 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.
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. To view the report in full, click here.
