Transcript Case for change presentation - Professional Records Standards Body

Using the e-discharge
summary headings
The case for change
Why it matters
‘Louise died in a Bristol A and E in plain view of everyone because the information
for her end of life care plan wasn’t at hand to me, or the paramedics, or her GP or
consultant. I live every day with the guilt of not helping her to die a good death for
lack of that information.’
Roberta Lovick,
Mother of Louise, 28
The risk
• A third of 10,000 patient safety incidents reviewed by the National
Reporting and Learning System were due to poor information
sharing on discharge.
• Half of medication errors and 20% of serious reactions to drugs are
due to poor information sharing in patient care records.
• A National Audit Office (NAO) review identified poor record keeping
by NHS bodies as a contributory factor in over 40% of medical
negligence claims.
• Poor record keeping is a common reason that nurses become
involved in disciplinary hearings.
Information standards matter…
• To patients, public and carers
… because they provide meaningful personal health information once to enable care planning, taking control of their records
• To clinical practice
…providing real time access to the information needed for good care, moving away from disparate fragmented systems and
impenetrable free text, with professionals agreeing best practice and capturing it in an auditable way,
• To integrated care and efficiency
… when information needs are agreed between the clinicians, professionals and patients and accessible to all who need it saving
time, resources and costs
• To safety
… resulting in reduced risk from for example medication errors, with full and timely access to complete information
• To research
... Structured, standardised care records enable access to greater quantity and far higher quality data to improve researtch potential
• To personalised care
…enables optimal care for each person
How long does it take?
Cambridge University Hospitals found that using the agreed headings
for their e-discharge summary meant they took on average:
 3-4 minutes for a routine simple admission (eg day case)
 7 minutes for a routine surgical admission
 9 minutes for a routine general medical admission (5-8 days)
including medicines reconciliation
 15 – 20 minutes for a complex discharge after an inpatient stay of
several weeks.
Perhaps a better question is: How long should a good discharge
summary take?
Why clinical engagement matters
Electronic records are coming
The standards determine the content of records but there is local
discretion about implementation
This is not an IT project: it is about using technology to support safer,
reliable, smooth patient care and good professional practice
For that to be achieved, clinicians need to inform local implementation
so that the system supports you, not the other way round.
Make sure your local implementation is informed by what information
you need, at what stage and what realistically works for you.
Find out more
The Professional Record Standards Body
www.theprsb.org.uk/projects
NHS Digital
http://systems.digital.nhs.uk/interop
References
NHS England Patient Safety Alert ref: Alert reference number:
NHS/PSA/W/2014/014 based on information from the National
Reporting and Learning System, 2014: access at:
https://www.england.nhs.uk/wp-content/uploads/2014/08/psa-imp-safof-discharge.pdf
UK National Audit Office Report: Handling Clinical Negligence Claims
in England, May 2001
Access at: https://www.nao.org.uk/wpcontent/uploads/2001/05/0001403.pdf
Medicines
The medication history should not simply be a list of a patient's drugs
and dosages.
Adverse drug reactions are often poorly recorded; of 117 patients, 50
had had a total of 81 previous adverse reactions, but only 75% were
recorded on medication charts and 57% and 64% in the medical and
nursing notes, respectively
Shenfield GM, Robb T, Duguid M. Recording previous adverse drug
reactions – a gap in the system. Br J Clin Pharmacol. 2001;51:623–
6. [PMC free article] [PubMed]