Access to critical patient information at the bedside

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

This investigation aims to improve patient safety by supporting staff to access critical information about patients, at their bedsides, in emergency situations.

In this investigation critical patient information has been defined as ‘information about patients that needs to be accessed rapidly and accurately to ensure correct care is delivered when it is required’. The types of information seen as ‘critical’ will depend on the particular context and situation.

In this investigation critical information was considered through a focus on patient identifiers (such as name and date of birth) and decisions relating to whether someone is recommended to receive cardiopulmonary resuscitation (CPR) if their heart stops (cardiac arrest).

Following someone’s heart stopping there is a high risk of death immediately or in the near future. Because of this, in some cases it may be decided that it is not recommended to try to treat a person with CPR. When a decision has been made that CPR is not recommended, that recommendation is documented in a person’s ‘Recommended Summary Plan for Emergency Care and Treatment’ (ReSPECT) or on a ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) form.

HSIB investigated the care of a Patient in a hospital who was found unresponsive in bed. A short time later he stopped breathing and his heart stopped. Help was immediately sought from the ward staff and a team gathered around the Patient’s bed. The team confirmed the Patient’s identity and noted that a decision had been made that he was not recommended to receive CPR if his heart stopped. CPR was not started.

Around 10 minutes later a nurse who had previously been caring for the Patient returned from their break and recognised that the Patient had been misidentified as the patient in the next bed. The Patient whose heart had stopped was recommended to receive CPR. CPR was immediately started, but despite this, the Patient died.

HSIB found that misidentification of the Patient, and limited access to critical information about the Patient at the bedside delayed his treatment. The investigation identified factors that contributed to the event. These included: access to computer systems, the display of information around the bed, and the sharing of information among staff to support familiarity with their patients.

A national investigation was undertaken to explore the factors that affect the ability of staff to access critical patient information at the bedside.

While the focus was on accessing someone’s CPR recommendation, findings may also be applicable to other forms of critical information. Findings related to patient identification will also be used as evidence for a future HSIB national learning report on positive patient identification.

The investigation involved engagement with hospitals across England, experts in fields associated with human factors and the display of information, and national bodies with the remit of policy and strategy in the NHS.

• Clinical staff are not always able to access accurate, critical patient information at bedsides to support decision making in emergencies.
• Patient identity wristbands are not consistently checked by staff during the undertaking of clinical tasks.
• The expectations of how staff should identify patients in an emergency and access critical information in relation to their care cannot always be met in practice because of limitations of technology and the work environment.
• Concerns around confidentiality can prevent the display of critical patient information at bedsides that may be needed to support safe care, particularly in emergencies.
• What and how critical patient information is displayed at the bedside varies across hospitals, with differences in positioning, visibility, readability and legibility.
• There is no national guidance to support consistency and visibility of critical patient information on low-technology displays (whiteboards/posters) or high-technology displays (via digital systems).
• Lighting on hospital wards can make it difficult for staff to see critical patient information, either through too little light, or too much light causing glare.
• Clinical staff consistently report difficulties accessing digital systems because of limited or poorly functioning hardware. This can result in the use of less reliable, paper-based systems for accessing critical patient information.
• Limited interoperability of multiple digital systems means critical patient information may not be accessible or consistent across all systems used in the care of a patient. Staff need to know which systems contain the information they need.
• Limited ability at a national level to influence the functionality of digital systems and their procurement means healthcare organisations are implementing systems with varying design and functionality.
• At the hospital level, the configuration of electronic patient record systems can introduce further safety risks where the infrastructure and staff training needs necessary for successful implementation have not been fully considered, and the needs of the clinical users have not been fully established.
• There is variation in the words and symbols used to indicate CPR recommendations, and in the level of understanding of CPR recommendations across hospitals, that may influence responses to cardiac arrests.
• Nursing handovers (where information about patients is passed between nursing staff at shift changes) may not provide the information staff need to care for their patients because of where and how they are undertaken. There is no national guidance on how best to undertake handovers of care.
• The implementation of electronic handover systems in clinical workplaces is limited by digital infrastructure, and systems that do not meet the needs of their users.