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Reference: Burnett, SJ, Deelchand, V, Franklin, BD et al., (2011). Missing clinical information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care. BMC health services research, 11 (1), 114.Citable link to this page:

 

Missing clinical information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care.

Abstract: BACKGROUND: In Britain over 39,000 reports were received by the National Patient Safety Agency relating to failures in documentation in 2007 and the UK Health Services Journal estimated in 2008 that over a million hospital outpatient visits each year might take place without the full record available. Despite these high numbers, the impact of missing clinical information has not been investigated for hospital outpatients in the UK.Studies in primary care in the USA have found 13.6% of patient consultations have missing clinical information, with this adversely affecting care in about half of cases, and in Australia 1.8% of medical errors were found to be due to the unavailability of clinical information.Our objectives were to assess the frequency, nature and potential impact on patient care of missing clinical information in NHS hospital outpatients and to assess the principal causes. This is the first study to present such figures for the UK and the first to look at how clinicians respond, including the associated impact on patient care. METHODS: Prospective descriptive study of missing information reported by surgeons, supplemented by interviews on the causes.Data were collected by surgeons in general, gastrointestinal, colorectal and vascular surgical clinics in three teaching hospitals across the UK for over a thousand outpatient appointments. Fifteen interviews were conducted with those involved in collating clinical information for these clinics.The study had ethics approval (Hammersmith and Queen Charlotte's and Chelsea Research Ethics Committee), reference number (09/H0707/27). Participants involved in the interviews signed a consent form and were offered the opportunity to review and agree the transcript of their interview before analysis. No patients were involved in this research. RESULTS: In 15% of outpatient consultations key items of clinical information were missing. Of these patients, 32% experienced a delay or disruption to their care and 20% had a risk of harm. In over half of cases the doctor relied on the patient for the information, making a clinical decision despite the information being missing in 20% of cases. Hospital mergers, temporary staff and non-integrated IT systems were contributing factors. CONCLUSIONS: If these findings are replicated across the NHS then almost 10 million outpatients are seen each year without key clinical information, creating over a million unnecessary appointments, and putting nearly 2 million patients at risk of harm. There is a need for a systematic, regular audit of the prevalence of missing clinical information. Only then will we know the impact on clinical decision making and patient care of new technology, service reorganisations and, crucially given the present financial climate, temporary or reduced staffing levels. Further research is needed to assess the relationship between missing clinical information and diagnostic errors; to examine the issue in primary care; and to consider the patients perspective.

Peer Review status:Peer reviewedPublication status:PublishedVersion:Publisher's version Funder: Health Foundation   Notes:© 2011 Burnett et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Bibliographic Details

Publisher: BioMed Central Ltd.

Publisher Website: http://www.biomedcentral.com/

Journal: BMC health services researchsee more from them

Publication Website: http://www.biomedcentral.com/bmchealthservres/

Issue Date: 2011

pages:114Identifiers

Urn: uuid:f204adca-3a8b-427d-8dca-9a55bf6200bd

Source identifier: 310425

Eissn: 1472-6963

Doi: https://doi.org/10.1186/1472-6963-11-114

Issn: 1472-6963 Item Description

Type: Journal article;

Language: eng

Version: Publisher's versionKeywords: Humans Prevalence Confidence Intervals Prospective Studies Patient Care Hospitals, Teaching Outpatient Clinics, Hospital Systems Analysis Outpatients Health Records, Personal State Medicine Referral and Consultation Risk Factors Great Britain Tiny URL: pubs:310425

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Author: Burnett, SJ - - - Deelchand, V - - - Franklin, BD - - - Moorthy, K - - - Vincent, C - institutionUniversity of Oxford Oxford, MSD

Source: https://ora.ox.ac.uk/objects/uuid:f204adca-3a8b-427d-8dca-9a55bf6200bd



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