Patient safety: Access to critical patient information must improve, says report

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

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 …