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The National Inpatient Medication Chart and it’s dangerous Document Folder. Australian experience. January 2007.
- Phillip J. Colquitt (13 January 2007)
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Missed opportunities
- Peter G Davies (16 January 2007)
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Hearts not numbers
- Guenther H Jonitz (17 January 2007)
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Systematic failure to deter daily clinical errors.
- William G Pickering (18 January 2007)
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Could Incident Reporting be Harming Patients?
- Peter D Gibson (19 January 2007)
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Errors in judgmet : To report or not to report?
- s dronacharya (27 January 2007)
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Phillip J. Colquitt, Technician/RN Independent Comment
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Using Word[R], I create printed out, computer generated memoranda, containing the now old fashioned form called the “sentence”, keeping a copy for reference. This, rather than fill the endlessy fenestrated computer based Incident Reports which, apart from what Vincent says[1], can be used by nurses as vehicles for bullying and victimization. For example, an anonymous concerned reporter names an individual but makes no entry in the clinical record. We have a computer incident reporting system here called ‘PRIME’, and insecure nurses who fail as leaders tend to threaten other nurses with such gems as ……“I’ll PRIME you”. That said, here in Australia, the National In-patient Medication Chart[NIMC] is in operation as of 2006[2]. The NIMC is a response to patient safety concerns related to medication error, caused in part, by having too many different versions of medication charts in one hospital and also in different hospitals in the same country[2]. While this standardization seems common sense, it is not yet accompanied by any standardization of the two ring A4 document folder containing the NIMC, or “bed chart” which usually resides at the foot of the bed, but which can be found anywhere in the ward in use by any number of health care workers. Leaving aside actions of basic life support[BLS] - it is precisely because these document folders/bed charts are highly mobile, that their speedy location becomes important in any medical emergency, as a quick overview of the patient’s current medication administration record is vital, and starts the process of addressing the question……. “Do our current actions or omissions in medication administration/prescribing help explain the emergency? ”……. Identifying the “bed chart” by bed number is the usual means of quickly locating it, in the absence of any electronic record via a mobile device. This is followed by confirming ID using the labels on the scripts. Yet labelling of bed chart/document folder itself, seems left to what may be called “diversity principles”, and any number of unauthoritative and arguably dangerous bed number labelling efforts can be seen. The saddest and most minimal of these efforts which comes to mind was a badly written bed number in biro on a piece of paper towel held in place by several pieces of visibly soiled porous surgical dressing tape, under which was a different bed number in felt tipped pen. When the sad paper label fell off, the patient in one bed got the medicine meant for a different patient. One might have thought that the vast resources and buying power of the health care system would have, by the third millennium, produced a bed chart/document folder which is a disposable consumable, which protects patient details from casual observation, which is labelled professionally, authoritatively, clearly, unambiguously, which is washable, which can be identified from several angles. And so on. [1] Vincent C. Incident reporting and patient safety. BMJ 2007;334:51 [2]http://www.safetyandquality.org/internet/safety/publishing.nsf/Content/national -inpatient-medication-chart Competing interests: None declared |
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Peter G Davies, GP Principal Keighley Road Surgery, Illingworth, Halifax. HX2 9LL
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I welcome this editorial (1), and the linked paper(2). Sadly I suspect most health systems operate on a basis of shooting the messenger rather than welcoming reports of incidents. The NHS may be supposed to be a learning organisation but I suspect it has the learning ability of a patient with Altzheimer's. The rapid changes and waves of redisorganisation help it to forget very easily. Despite the rhetoric most parts of the NHS are still defensive and trying to avoid and reduce complaints and incident reports. They want a few to show they are doing something, but not too many, or any that they have to do anything about. For practitioners at present few of us believe that any useful action will flow from reporting an incident. 1. Vincent, C (2007) Incident reporting and patient safety BMJ 2007; 334: 51 2. Ali Baba-Akbari Sari, Trevor A Sheldon, Alison Cracknell, Alastair Turnbull (2007) Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review BMJ 2007;334:79 Competing interests: None declared |
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Guenther H Jonitz, Vice Chairman German Coalition for Patient Safety D 10969 Berlin Germany
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It is less important to get new numbers or data. We have enough knowledge about safer working conditions and safer health care. It is much more important to get "to the heart of the doctors" (Colin Feek, Ministry of Health, NZ). You will get good information from reporting systems if the ones who are responsible for the local system (e.g. hospital managers) are working with this information. If you don't act on patient safety information, if numbers and data are used to threaten or to shame doctors and nurses, all activities will fail. And, mandatory systems are always voluntary, because you decide what to tell. Competing interests: None declared |
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William G Pickering, Doctor Newcastle upon Tyne NE3 4AL
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Systematic failure to deter daily clinical errors. By “patient safety incident” does Professor Vincent actually mean the opposite, ‘potential or actual patient harm incident’ — which term would perhaps concentrate minds better [1]? He provides no clinical example to illustrate his view and aim. How would his plans function to rapidly identify and stop recurrence of an “incident” of a doctor taking a slipshod clinical history resulting in a dire yet preventable outcome? He was a “paid adviser” for the expensive NPSA which thought “the reporting of incidents” was a good idea. He now sees “the vast amounts of money poured into this” as near useless (hence his article). He confides it was “hard to see why” they went down that cul-de-sac (ie. why they wasted tax- payers’ money). Patients would agree. He wants instead “systematic data collection”, “systematic assessment of error and harm” and “if incident reports are to be of real value they should be reviewed by clinicians”. Yes. Independent clinicians. Nationwide and daily [eg. 2,3]. Complaints are crucial “incidents” and are one excellent place to start – although Vincent bemoans that “their management dominates” things. So it should. And many complaints need a more definitive action than “review”. He wants “active surveillance of salient events” and then “analysis and safety improvement programmes” — which terms smack of the lofty intentions and undefined action with which medico-politicians feel so comfortable, not to mention their expense. Patients themselves know what is needed to curtail clinical errors and Vincent (who is in “research”) might usefully ask them – starting with those who have been touched by medical error. There is plenty of choice. William G Pickering. wgpi@hotmail.com 17.1.07 References: 1. Vincent C. Incident reporting and patient safety BMJ 2007;334:51 (13 January) 2. Pickering W.G. An independent medical inspectorate. In: Gladstone D, ed. Regulating doctors. London: Institute for the Study of Civil Society, 2000: 47-63. ISBN 1-903 386-01. [http://www.civitas.org.uk/pdf/cs01.pdf] 3. Pickering W.G. Systematic clinical accountability is required. BMJ Nov 2003; 327: 1109 Competing interests: None declared |
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Peter D Gibson, Consultant North Manchester General Hospital M8 5RB
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Dear Editor Re. Incident reporting and patient safety Is the current NHS Hospital Patient Safety Incident Reporting scheme a waste of time? Is it worsening patient care by diverting time from the care of patients to the completion of forms? Why is the UK General Medical Council requiring us to report all clinical incidents1? Is there good quality evidence that the reporting of extremely large numbers of minor incidents is improving patient care? What is the evidence that a reporting system base in an NHS district general hospital improves patient care? Why do hospital trusts ask us to report all incidents, when they only look in detail at the minority of most serious (“orange” and “red”) incidents? According to the study by Sari and colleagues2 there will be (on average) one incident reported for every 3 hospital admissions. It takes approximately 20 minutes to find the incident reporting book, complete it and return it to the relevant person / place (educated guess). If all incidents were reported (as is required by the UK General Medical Council1), how much medical and nursing time would this consume? This time would either mean that other patients would receive less care or staff would leave late. Neither is a strong motivating factor for completion of patient incident reporting forms. The Chief Medical Officer for England (Professor Liam Donaldson) clearly sees this as a problem3. The editorial states that “analysing a small number of incidents thoroughly is probably more valuable than a cursory overview of a large number of incidents”4. Yet we are being asked to report an enormous number of incidents. Is it possible that patients are being harmed by the system because more time is being spent filling in forms (which provide little benefit) rather than caring for patients? 1.http://www.gmc- uk.org/guidance/current/library/management_for_doctors.pdf 2.Sari AB, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007;334:79-81 3.http://www.dh.gov.uk/assetRoot/04/14/16/72/04141672.pdf 4.Vincent C. Incident reporting and patient safety. BMJ 2007;334:51 Yours faithfully Dr Peter Gibson Competing interests: None declared |
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s dronacharya, Hospital doctor LE4 6PN
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Much can be said about patient’s safety. In most everyday scenarios, we are talking about mistakes by junior doctors in training or by non- medical/para medical staff. What happens when the error of judgment comes from much senior person, i.e. Consultant. In the current system in NHS, Consultant is where the buck ends. They take overall responsibility for patients care. Often they have to answer, even when patient is admitted under their care. What happens really when the mistakes comes from the Consultant? To make it worse, if this gets spotted by someone junior? Is it ethical for the junior to turn a blind eye? Should the junior become more vigilant? Should the junior report to whosoever it matters and risk being labelled a whistle blower and incur the wrath of the management? There are many guidelines, but when it comes to facing the guillotine, why the juniors get sidelined? Manipulation of people and forces become apparent and suddenly, the juniors training is questioned? Junior find him/herself alone, unsupported, being placed under extreme supervision and alone to defend oneself. Is this system failure? I feel that this is very cynical. This emerges form the belief we have grown up with that “Consultant knows everything”. Alas! That’s not the case in many situations. Especially, with training time getting shorter and doctors spending more time in acute on calls and less for speciality training. The pressure from the EWTD is a confounding factor in reducing quality training and the training has actually shrunk to getting some pieces of papers signed, ticks in appropriate boxes. Gone are the days when clinical experience did matter. Gone are the days when clinical skills were hammered into. Now a day, as long as one gets signed off for a task, and has shown competencies in a paper, they are competent. Is it true? Rising number of incident reporting mirrors this. SO god me when I am old and I have to spend my time on a trolley which gets moved from A/E to MAU to Clinical decision unit to ward, in worst case scenario, moved to a different hospital, as I am breaching trolley wait time in one area/hospital. I will also have to prey that some one who has all the ticks would treat me and all competencies signed for. So help me god. I am a pessimist? No, Just hopeful. Competing interests: None declared |
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