Patient safety: Access to critical patient information must improve, says report BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p273 (Published 02 February 2023)Cite this as: BMJ 2023;380:p273
An independent safety body has called for improved access to critical patient information at bedsides following the death of a 79 year old man who was not given cardiopulmonary resuscitation (CPR) in hospital because he was misidentified.1 <https://www.bmj.com/content/380/bmj.p273#ref-1>
The Health Services Investigation Body (HSIB) carried out an investigation after an inpatient on a ward in an acute hospital was found unresponsive by a physiotherapy team. A nurse, who had not been caring for the patient, looked at a typed nursing handover sheet and noted that “do not attempt CPR” was recorded. As a result, when the patient went into cardiac arrest staff made him comfortable and did not start CPR.
Around 10 minutes later the nurse who had previously been caring for the patient returned from a break and recognised that the patient had been misidentified as the patient in the next bed. The two patients had the same first name but different last names and dates of birth. A crash call was put out to alert the cardiac arrest team but attempts to treat him were unsuccessful.
HSIB found that several factors contributed to the man’s death including access to computer systems, the display of information around the bed, and sharing of information. HSIB, which is funded by the Department of Health and Social Care, then carried out a national investigation to explore factors that affect the ability of staff to access critical patient information at the bedside.
The investigation found that clinical staff are not always able to access accurate, critical patient information at bedsides to support decision making in emergencies. Patient identity wristbands are not consistently checked by staff during the undertaking of clinica
HIFA Profile: Richard Fitton is a retired family doctor - GP. Professional interests: Health literacy, patient partnership of trust and implementation of healthcare with professionals, family and public involvement in the prevention of modern lifestyle diseases, patients using access to professional records to overcome confidentiality barriers to care, patients as part of the policing of the use of their patient data Email address: richardpeterfitton7 AT gmail.com
