Douglas Noble on patient safety

douglas noble
Ineffectively communicated clinical information has been estimated to be responsible for up to 10% of all preventable medical errors.  Stanton et al, in their recent book on clinical leadership, reveal that 70% of information is communicated non-verbally.

Whatever way it’s delivered to us, vast quantities of information are around us.  Yet, how often do we think about the way we receive, record and communicate this routine material?  Risk awareness is often low; acceptance of everyday methods of dealing with information, high.

Some information is just background noise: the phosphate level or eosinophil count.  But what of the critical information, the in-patient CT head scan that goes unreported last thing on a Friday, or the potassium of 6.66?

Take a typical day as a doctor and consider the multitude of information that requires action.  Many of us working night shifts have often wondered why we seem to be the only one dealing with an in-patient’s problems on sequential shifts, always at 3 am.  What’s wrong with information communicated in the record: ‘for the day-team to deal with’? Could it be the scrappy piece of paper crossed out all over the place that we carry everywhere?  Is this an effective method of recording and transmitting information? Or actually, maybe, an effective way of corrupting it?  Perhaps it’s the absence of any information recording from the receiver at verbal handover, which we may have thought unusual, but have assumed by the ‘non-verbal’ look on their face, must be due to a photographic memory.  Or possibly it’s down to consulting the wrong person, perhaps too senior.  Let’s not forget it’s often the most junior member of every clinical team who actually records information in the medical record.  Maybe they should be approached for effective handover.  In a conversation I had recently with an American medic, he expressed disbelief that in the UK we’d entrust the task of recording information from clinical consultations to the doctor with the least experience and qualifications.

Information from investigations should be more watertight, after all it’s computerised and we’re in the age of the electronic patient record – a glorious period – where primary and secondary care are electronically one, systems are uniform and errors flagged up automatically … no, really, these systems do exist.

In some hospitals investigation results are received on multiple separate computer software packages through a range of failing computer terminals.  Usually the most antiquated delivers blood results, one provides radiological information, and another has the patient’s diagnosis, details and other miscellaneous data.

Blood results are still regularly hand copied from computer screens into reams of different folders on wards throughout hospitals (despite years of us all wondering why we do it like this).  Independent double checking dies another day, every day.  To cap it all off, these same blood results appear between 3 days to 6 weeks later on BBC style computer printouts for sign off – in honesty, I don’t think anyone knows what to do with these.

The radiology system is the most advanced and affords the most hope, but the reports sometimes take ages to appear.  Nevertheless vigilant doctors harangue radiologists for verbal reports which are dutifully scribed in the medical record.  Despite this, dreaded addendums appear on computer systems sometime later!

Douglas Noble has worked in surgery, emergency medicine, public health and for WHO Patient Safety. From 2006 to 2008 he was clinical adviser to chief medical officer for England, Sir Liam Donaldson.