Apart from this being a horrible situation for all involved, the key recommendation was to make sure the paper process was better so you don’t lose it…
I hope that this doesn’t horrify you too much, but this sort of thing happens all of the time. It is fortunately rare that a truly bad outcome results, and even rarer that it rises to the HDC / press.
Most of us are in the public system are in a state of learned helplessness over this. Personally, I complain about it and do awkward things that make me unpopular like delay the start of people’s operations until the notes are found, but I am in a small minority. Incident reports about it are rarely made.
The thing I find interesting is that is often worse in this time of hybrid records; if 70% of the health record is available electronically, there is much less impetus to get the (often quite important) 30% paper remainder reliably - or at all. This was particularly noticeable to me in Birmingham, where the anaesthetic records happened to be in that 30%. The very human response of my colleagues was to lower the standard of care. This I found very difficult to accept!
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Hi Nathan, I agree with you that a hybrid environment can be even more dangerous. When we were rolling out the ieMR at QLD Health we went to great lengths to deliver the full rollout for a hospital as quickly as possible in recognition of the patient safety issues that can be caused during the transition period. We would have all the main areas, ED, Theatres, Inpatients, Maternity, Rad, Path etc all across within 48 hours, and all areas (e.g. community, outpatients etc) within a max of two weeks. We would also have dedicated patient safety teams running 24 * 7 during the two-week period to be hyper vigilant of any transition issues.
Saddest part about the above story is that the technology has existed for 20+ years to prevent that patients’ death and yet HNZ is not even at a business case stage to move most of their clinical care to an integrated electronic medical record system that is suitable for an enterprise size organisation.
Even sadder is the above example statistically is an outlier compared to adverse events from medication errors which technology can greatly reduce, (and has also been available for 20+ years).
I must admit Jon, I read the recommendation re paper and thought this was a huge opportunity missed in terms of not pushing for electronic systems that negate the need to physically pass pieces of paper around.
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For sure because interoperability saves lives
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In 2023, there was a similar article about a patient who waited for more than six hours and returned to an ambulance a few hours later had a massive” brain haemorrhage.
Compared to the current article, the figures are similar; initial observations are taken after six hours, and the first registrar saw nine hours after arrival.
In 2018, news article wrote that “ patients were being seen within the six hours”
Certainly, 6 years later, the situation is still the same. The triage system, emergency waiting time, and clinical handover need serious evaluation. The electronic system would prevent lost clinical information and improve communication, but it may not improve initial review time, which is currently 6 to 9 hours.
@jon_herries
HDC report clearly missing the key issues in this case. Patient medicines are easily accessible in the EMR (HCS) via HealthOne and Medicines viewer in South Island (plus via the Ambulance Care Summary) and these would be the go-to places for medicines. The care home notes are sometimes useful, but rarely critical for patient care in the ED. There is excessive focus on the yellow care home handover process, when the main issue is clinical decision-making.