University College Hospitals have an impressive digital imaging system that keeps images of patient documentation, X-Rays, CT and PET scans etc.
However, the idea of the "paperless office" is very far from everday reality. Nurses in particular seem to spend ages reading and writing things on paper.
One or two nurses and an Anaesthetist had sat reading Carol's paper casenote file at the desk while we were waiting for something to happen in the Surgical Admissions Unit (Personal v Professional ). Half way through through the interminable morning Carol decided to break the monotony of the empty room by thumbing through her notes on the desk. They were clearly marked with her name and patient number. She turned to the PET scan report to find with incredulity, that it revealed that she had advanced adenocarcinoma of the lung which had invaded the tissue of the diaphragm. The report also revealed that she was a heavy smoker.
Mmm shome mishtake surely -Ed?
The report in fact related to a Carole H***** of Hertfordshire. Misfiling of notes relating to patients with similar names is one of the obvious mistakes which is why DoB, addresses and hospital number are there in the records to prevent it happening. However, just below that was another report relating to a male, a Dennis Q****. No where was a report of Carol Harding's PET scan conducted a month ago.
We were shocked. Several people had looked at these notes, and apart from the CT Biopsy results, the PET scan was probably the next most relevant diagnostic. Yet no-one had noticed, including the Anaesthetic Registrar. Suddenly it became clear why she had asked Carol about her smoking during the pre-op anaesthetic assessment.
As we were discussing this, the nurse came back into the room after a long absence and saw us with the casenotes on the bed. "I'm sorry, you are not allowed to read your notes", she said, with an outstretched hand signalling Carol was to hand them over. "I think I have every right to". "No you need the doctor's permission". As Carol had read them anyway, she handed them over.
It is of course part of the Data Protection Act, and the NHS Constitution that patients have the right to access their notes. One of the reasons for this is to correct inaccurate data in their records.
The NHS 2011 Care Record Guarantee states:
It is good practice for people in the NHS who provide your care to:
• discuss and agree with you what they are going to record about you;
• give you a copy of letters they are writing about you; and
• show you what they have recorded about you, if you ask.
The NHS 2011 Care Record Guarantee states:
It is good practice for people in the NHS who provide your care to:
• discuss and agree with you what they are going to record about you;
• give you a copy of letters they are writing about you; and
• show you what they have recorded about you, if you ask.
The Surgical Locum came to read the same notes, and before the Consent Forms were signed Carol informed him of the error. Unlike all the other clinical staff that had looked at them, he had noticed, and removed the misfiled records. He agreed to have a word with someone.
Within half an hour, a "Ward Manager" appeared and seemed to start off with the line that Carol shouldn't have been reading them. In the end she made an apology and shuffled off. Next, the Thoracic Clinical Nurse Specialist appeared, all smiles, and apologised for the mistake. Her P.R. role in smoothing over complaining patients was noted elsewhere. Finally, a business-like woman in a smart trouser suit appeared announcing herself as the "Matron", who wished to assure Carol that no clinical decisions were taken on the basis of mis-filed diagnostic reports in the casenotes, as the computerised records were the first port of call. Yeah right, so how does that explain that the anaesthetic registrar was proceding on the basis that Carol was a heavy smoker? Would she be prepping her for a lung removal or diaphragmatic resection?
All three apologies were clearly damage limitation exercises. It was interesting that the potential of a medico-legal complaint got these characters to magically appear, but they were no where in sight when the Surgical Admissions Unit clearly needed some managerial intervention.
What has happened to Attention to Detail? What sort of calibre of staff is it that misfiles not just one report, but two? What sort of clinical discernment is present in nursing staff and a Registrar that don't notice such glaring errors?
Within half an hour, a "Ward Manager" appeared and seemed to start off with the line that Carol shouldn't have been reading them. In the end she made an apology and shuffled off. Next, the Thoracic Clinical Nurse Specialist appeared, all smiles, and apologised for the mistake. Her P.R. role in smoothing over complaining patients was noted elsewhere. Finally, a business-like woman in a smart trouser suit appeared announcing herself as the "Matron", who wished to assure Carol that no clinical decisions were taken on the basis of mis-filed diagnostic reports in the casenotes, as the computerised records were the first port of call. Yeah right, so how does that explain that the anaesthetic registrar was proceding on the basis that Carol was a heavy smoker? Would she be prepping her for a lung removal or diaphragmatic resection?
All three apologies were clearly damage limitation exercises. It was interesting that the potential of a medico-legal complaint got these characters to magically appear, but they were no where in sight when the Surgical Admissions Unit clearly needed some managerial intervention.
What has happened to Attention to Detail? What sort of calibre of staff is it that misfiles not just one report, but two? What sort of clinical discernment is present in nursing staff and a Registrar that don't notice such glaring errors?
As an addendum, take a look at this Nursing Referral Form. It was filled in by a nurse on discharge in order to get the sutures removed at our local GP Surgery.
Look at the operation she has put down. Carol had a median sternotomy - cutting vertically through the middle of the breastbone to gain access. A sternectomy is the complete surgical REMOVAL of the breastbone. It is a major extremely unpleasant procedure. The difference between an -otomy and an -ectomy is first year nursing student basics. And the operation was not a biopsy. A biopsy retrieves a tissue-sample. It was excision or removal of thymoma. Again, if there is lack of attention to detail here, then one might reasonably question, does this lack of clinical precision extend to other areas of nursing record-keeping? Will someone make a mistake where it really matters?
Look at the operation she has put down. Carol had a median sternotomy - cutting vertically through the middle of the breastbone to gain access. A sternectomy is the complete surgical REMOVAL of the breastbone. It is a major extremely unpleasant procedure. The difference between an -otomy and an -ectomy is first year nursing student basics. And the operation was not a biopsy. A biopsy retrieves a tissue-sample. It was excision or removal of thymoma. Again, if there is lack of attention to detail here, then one might reasonably question, does this lack of clinical precision extend to other areas of nursing record-keeping? Will someone make a mistake where it really matters?
There is value in recording and highlighting your experiences (and Carol's in her later post) to hopefully bring it to the Trust's attention. Truly shocking at such slack filing and record keeping (not to mention the errors in the nursing report). In the past I would have put the blame on poorly paid inexperienced filing clerks (and possibly secretaries - though not all) trying to cope with a huge backlog of filing of results in an understaffed system. Since Labour's investment in the NHS, I am not sure that can be said any longer. The amount of training and resources that goes into the NHS means there is really no excuse.
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