More clinical audits are key to improving quality of care, says NHS audit chief

BMJ 2009; 339 doi: (Published 21 September 2009) Cite this as: BMJ 2009;339:b3878

Paper safety, not patient safety?

Dear Sir/madam

Guidelines issued by the Department of Health in
2007 on the prevention of venothromboebolism (VTE) were
accompanied with recommendations for improved working
practices. These include a documented mandatory risk
assessment for every hospitalised patient and compliance
with such standards to be monitored by the Healthcare

In our District General Hospital this has resulted
in all adult medical admissions undergoing such a process
since April 2009, ideally performed at the start of their
inpatient stay. A proforma is completed assessing risk
factors and contraindications to use of low molecular weight
heparin and TED stockings. The patient is then assigned a
risk category - either not at risk or requiring one or both
of the above treatment options.

Recently the completion of this document has been audited
locally. Favourable outcomes included full and early
completion of the paperwork. However this did not evaluate
the prescription of the above prophylaxis or indeed its
effective and timely administration. Thus a patient could
have a perfectly documented risk assessment but be receiving
no clinical benefits. Does this equate to patient safety or
good clinical practice?

In recent years the quantity of paperwork for any single
intervention has markedly increased. The insertion of a
cannula in our trust is now accompanied by two forms
requiring completion. Such documents are generally filled
out by junior medical staff and clearly come at a time of
reduced working hours in the accordance with the European
working time directive.

We recognise the importance of both risk management and
audit but increasing this can compromise time spent with the
patients themselves. If such strategies result in improved
clinical practice and patient care in the long-term then
this sacrifice may be worth while. However, if this only
results in better completion of paper work than clearly this
method needs to be re-evaluated.

Competing interests:
None declared

Competing interests: No competing interests

05 October 2009
Belinda Sandler
SHO cardiology
John M Hounsell, Thomas Semple
Lister Hospital, SG1 4AB