This blog post was published by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.
The patient safety guru Don Berwick once said that communication is the mainstay of safety. It is a statement that will resonate with anyone working in the NHS and wider healthcare. We rely on good communication to keep our patients safe and increasingly we are dependent on electronic systems to deliver these communications.
The design of these systems, the interconnectivity between them, and the degree to which they impact on effective communication, is often highlighted as an issue in HSIB’s national investigations.
Why is this an issue?
Healthcare may be delivered across different organisations that have each purchased different clinical and administrative electronic systems. These systems have been chosen to meet the needs of the organisation at a moment in time and the choice may have been influenced by factors such as cost. The requirement for connectivity with systems purchased by other organisations may not have been relevant or predicted at that time.
These same issues can apply to systems in different departments within a single organisation. With changes in the delivery of healthcare, for example the increase in remote working and staff needing access to information from multiple departments, the problems of poor interconnectivity are exacerbated.
Problems can be compounded if all relevant teams are not involved in the purchasing decisions and testing of new electronic systems. Without such input, the full functionality needed by the system may not be appreciated and the valuable input of staff into helping procure and design systems that work for them may be lost.
What is the impact on patient safety?
Where systems are unable to communicate with each other, a human interaction is often required to bridge the gap.
The impact on patient safety in the NHS in England is highlighted in three HSIB national investigations to date:
- Failures in communication or follow-up of unexpected significant radiological findings.
- Outpatient appointments intended but not booked after inpatient stays.
- Clinical investigation booking systems failures.
Failures in communication or follow-up of unexpected significant radiological findings
An X-ray showing a possible lung cancer was not followed up and resulted in a delayed diagnosis for the patient. The failures in communication investigation highlighted the need for clinical results systems to provide assurance that significant results have been acknowledged and, ideally, acted upon by the relevant people.
With challenging workloads and clinicians often working across multiple sites – not to mention specific challenges that can be faced in locum and agency staff accessing electronic systems – it is imperative that electronic systems provide important information in an obvious way, and that the system prompts acknowledgement of receipt with in-built escalation processes where that acknowledgement is not received.
Outpatient appointments intended but not booked after inpatient stays
A patient was discharged from hospital on two separate occasions with a plan to follow-up in outpatient clinics. Neither of the outpatient appointments were made. The outpatient appointments investigation found that the appointment booking process relied on the vigilance and diligence of staff and patients to ensure required follow-up appointments were made.
The discharge letter instructed both the hospital and the GP to arrange a follow-up appointment, leading to confusion about who needed to take responsibility for this task. There was no assurance mechanism to identify when intended follow-up appointments had not been made and GPs told the investigation that sometimes the only way they would know if a follow-up appointment was booked was if they rang the hospital to check or if a patient notified them that they had not received an appointment.
Clinical investigation booking systems failures
A patient scan was requested on an electronic system by a clinical team in a hospital but that system did not interact with the hospital’s appointment booking system. The system also did not help staff account for the needs of patients who may not read English, resulting in further letters not being understood. These factors contributed to a patient’s scan not being rescheduled following a cancellation, and further scans not being able to take place.
The booking systems failures investigation highlighted that requests for scans had to be physically printed, and the details entered manually by administrative staff into the appointment booking system. This also included the need to seek clarification from clinical colleagues about what type of appointment was needed, and how this should be communicated. Administrative staff had not been involved in assessing and testing electronic booking systems before they were implemented and told the investigation that this placed a great deal of responsibility on individual staff as a point of failure.
The way forward
There is still a long way to go in improving systems to ensure that important information about a patient’s care is easily accessible and communicated effectively.
Electronic systems in the NHS need to support effective communication to promote patient safety. This requires interconnectivity between the different systems in use, and the need for systems to be able to provide assurance that the appropriate actions have been taken for patient safety. Importantly, the design of those systems needs to take account of the needs of those staff using them and to reduce the reliance on individual staff to make the systems work.
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