Fragmented NHS record access and information sharing
Failures to share patient records and clinical information between NHS providers, including at transfer, discharge, and across organisational boundaries, leading to fragmented care and patient safety risks.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
HSSIB recommendation
100match
Electronic patient record systems – electronic referrals for ongoing care
Organisations can improve patient safety by ensuring the mandated requirements for digital clinical risk management (under DCB0160) for the deployment of the electronic referral service (e-RS) are achieved. For general practices and integrated care boards this includes agreeing responsibilities for the digital clinical risk management of e-RS. This is to enable identification and mitigation of risks to patient...
Matched on
terms: acces, information, record, sharing
HSSIB recommendation
100match
Access to critical patient information at the bedside
HSIB recommends that NHS England assesses the priority, feasibility, and impact of future research into what and how critical information pertaining to the emergency care of patients in the acute hospital setting can be readily and reliably accessed at a patient’s bedside.
Matched on
terms: acces, information, nhs
Inquiry recommendation
100match
COVID-M4.4 - Proportionate Access to Linked Healthcare Records
The UK government and devolved administrations should work together, with their respective health delivery services, to facilitate and coordinate regulatory bodies' access to healthcare records in order to make the post-authorisation safety monitoring of new vaccines and therapeutics more efficient. In particular, the Medicines and Healthcare products Regulatory Agency should be granted specific and proportionate access to comprehensive...
Matched on
terms: acces, information, record
Committee recommendation
99match
#8 - Twenty-Second Report - Digital transformation in the NHS
NHS England & NHS Improvement (NHSE&I) increasingly seek to plan and coordinate patient care through partnerships of local health and care organisations, known as sustainability and transformation partnerships (STPs) and integrated care systems (ICSs). This makes sharing data between organisations essential to enable electronic patient records to be seen and updated by clinicians in different organisations such as...
Matched on
terms: information, nhs, record, sharing
PFD report
97match
Simon McAndrew
The coroner raised concerns about poor communication between different NHS Trusts, noting that important information regarding Mr McAndrew's psychiatric care was not effectively shared or accessed, leading to an inappropriate referral.
Matched on
terms: acces, information, nhs
PFD report
97match
Jacob Sulaiman
The coroner identified issues with insufficient information sharing and accessibility between care services regarding a patient's recent contacts, leading to an incomplete picture for response officers and potentially affecting assessment and management.
Matched on
terms: acces, information, sharing
Inquiry recommendation
97match
SP50 - Healthcare trust risk information visibility
The Department of Health and Social Care / NHS England should ensure that all healthcare trusts involved in the care of children and young people who are at risk of acts of violence against others have systems that ensure that: 1. Key information regarding current and historic risk information is readily visible to treating clinicians in a summarised...
Matched on
terms: information, nhs, record
HSSIB recommendation
94match
Electronic patient record (EPR) systems – thematic review
National bodies responsible for providing digital advice and guidance to NHS organisations can improve patient safety by clarifying consistent definitions for design-related IT terms – such as usability and functionality – and sharing guidance on how to apply design principles to electronic patient record system configuration and optimisation.
Matched on
terms: nhs, record, sharing
PFD report
93match
Denise Parramore
The coroner noted insufficient communication between psychiatric services and the general practitioner regarding a patient's Tramadol prescription. There is a need for open, two-way information sharing and access to documentation between primary and secondary care.
Matched on
terms: acces, information, sharing
HSSIB recommendation
93match
Online prescribing: challenges and opportunities to improve patient safety
HSSIB recommends that the Department of Health and Social Care develops a policy and implements a mechanism to enable appropriate NHS patient information to be shared with independent prescribing organisations. This is to ensure independent prescribing organisations can access verified patient information, with patients’ consent, to inform prescribing decisions.
Matched on
terms: acces, information, nhs
GIRFT recommendation
93match
Endocrinology
Reduce unnecessary duplication of diagnostic tests to streamline initial referral and avoid wastage. Appropriate information sharing is an essential part of the provision of safe and effective care. a GIRFT and the Society for Endocrinology to provide guidance on which diagnostic tests are appropriate to be carried out or commissioned by GPs prior to referral to secondary or...
Matched on
terms: information, nhs, record, sharing
GIRFT recommendation
90match
Paediatric Critical Care
Improve the accuracy and completeness of PCC data capture and flow. a All providers should implement a full electronic patient report (EPR). This should include automated data capture from ventilators, monitoring and infusion devices, and electronic prescribing. Ensure digital connectivity standards are specified to allow capture and automated upload of PCC activity. b Ensure that every paediatric provider...
Matched on
terms: acces, information, nhs
HSSIB recommendation
90match
Surgical care of NHS patients in independent hospitals
HSIB recommends that NHSX expands its work programme addressing the challenges associated with interoperability of information systems used in healthcare to include transfer of information between the NHS and independent sector in support of safe care delivery.
Matched on
terms: information, nhs
PFD report
89match
Stephen Leven
The coroner identified a lack of secondary care access to GP records, such as a patient's haemophilia diagnosis, which risks future deaths if critical medical information is unavailable.
Matched on
terms: acces, information, record
PFD report
89match
Timothy Smedley
The coroner identified fragmented care from out-of-hours services due to a lack of joint NHS record access. Concerns also included difficulties for patients with alcohol addiction accessing timely mental health services and insufficient awareness of their complex needs.
Matched on
terms: acces, fragmented, nhs, record
Committee recommendation
89match
#7 - 79th Report - Supporting people with frailty outside hospitals
For all patients diagnosed with severe frailty, the GP contract requires GPs to do a clinical review. This includes a review of the patient’s medication, a falls risk assessment and a discussion with the patient of the benefits of having an enriched summary care record that provides healthcare professionals with access to core details about the patient (medications,...
Matched on
terms: acces, information, nhs, record
Committee recommendation
89match
#42 - Fifth Report: Home Office preparedness for COVID-19 (coronavirus): management of the borders
We are concerned that Ministers do not seem to have access to information about prevalence rates internationally, and there is confusion about what information is held by the Department for Health and Social Care, as well as the interaction between different agencies including Public Health England, NHS Test and Trace and the Joint Biosecurity Centre and SAGE. We...
Matched on
terms: acces, information, nhs
HSSIB recommendation
89match
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June...
HSIB recommends that NHSX develops specifications for electronic patient record (EPR) systems that require adherence to national interconnectivity standards for the exchange of core maternity healthcare information. The specifications should include functionality to enable both women and pregnant people and professionals to add to the record, and also support alerting functionality.
Matched on
terms: information, nhs, record
HSSIB recommendation
89match
Advanced airway management in patients with a known complex disease
HSSIB recommends that NHS England identifies and implements a system for sharing clinical information about people with a known difficult airway. This is to improve access to this information for healthcare professionals and reduce the risk of a person’s known difficult airway not being recognised.
Matched on
terms: acces, information, nhs, sharing
GIRFT recommendation
89match
Ophthalmology
Facilitate joint working within providers, between providers and with primary care to continue the rollout of networked EPR in ophthalmology. Actions: a) Trusts to consider using the RCOphth Electronic Medical Records Standards to inform any EPR procurement exercise and make capability for information sharing a key criterion. b) Providers to explore feasibility of using existing EPR systems to...
Matched on
terms: information, record, sharing
HSSIB recommendation
86match
Healthcare provision in prisons: data sharing and IT
HSSIB recommends that HM Prison and Probation Service ensures that the development of the Digital Prison Services system includes interoperability with healthcare IT systems. This will ensure that information which does not impinge on the confidentiality requirements of either system, relevant to the safety and wellbeing of staff, patients and other prisoners, is available at the point of...
Matched on
terms: information, sharing
Inquiry recommendation
86match
12b - Information sharing between providers
If the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.
Matched on
terms: information, sharing
PFD report
85match
Edward Gascoigne
Clinicians experienced difficulty accessing comprehensive patient information because relevant data was stored in disparate record 'silos'. The coroner noted a concern that the current approach to NHS record sharing does not adequately address these risks.
Matched on
terms: acces, information, nhs, record
HSSIB recommendation
85match
Invasive procedures in patients with sickle cell disease
HSIB recommends that NHS England identifies and implements a system for sharing clinical information about patients with sickle cell disease to improve access to this information for clinicians, and reduce the risk of a patient’s sickle cell disease not being treated consistently.
Matched on
terms: acces, information, nhs, sharing
CQC action
85match
Mount Vernon Cancer Centre
The trust must ensure that all necessary staff have access to records and information systems to enable them to review patient details. This includes investigation results from other providers.
Matched on
terms: acces, information, record
Scottish FAI
85match
Stephen Masson
The sheriff having considered the information presented at the Inquiry, in terms of section 26(1)(b) of the Act, in having regard to matters mentioned in section 26(4) of the Act recommends that: (1) A note of all ongoing prescriptions currently prescribed to a patient should be registered with the NHS regardless of the prescriber to allow healthcare professionals...
Matched on
terms: acces, information, nhs
Scottish FAI
84match
Erin Casey and Christina Fiorre Ilia
I recommend the following:- (1) The vast majority of patients with epilepsy, or their parents or carers where appropriate, should be advised of the risk of SUDEP on first diagnosis or if , in the particular circumstances of that patient, there are exceptional circumstances for delaying immediate provision of the information, then within a very short time thereafter....
Matched on
terms: acces, information, nhs, record
HSSIB recommendation
83match
Placement of nasogastric tubes
It may be beneficial if national organisations including the Medicines and Healthcare products Regulatory Agency, NHS Supply Chain and NHS England and NHS Improvement review arrangements for ensuring all medical device related incidents, Yellow Card reports, or other device safety related information, including any involving concerns with pH or X-ray in the context of nasogastric tubes, are shared...
Matched on
terms: information, nhs
Inquiry recommendation
82match
45 - Local diocesan information sharing protocols
The Church of England, the Church in Wales and statutory partners should ensure that information-sharing protocols are in place at a local level between dioceses and statutory partners.
Matched on
terms: information, sharing
Inquiry recommendation
82match
44 - Church of England/Wales information sharing protocol
The Church of England and the Church in Wales should agree and implement a formal information-sharing protocol. This should include the sharing of information about clergy who move between the two Churches.
Matched on
terms: information, sharing
PFD report
81match
Anne Whitworth
Incompatible computer systems prevented out-of-hours doctors from accessing the patient's full medical records, impacting treatment decisions and leading to a missed opportunity for escalation of care.
Matched on
terms: acces, record
PFD report
81match
Leah Ratheram
The coroner identified uncoordinated mental health care for young adults (18-25) in crisis, with unclear responsibility and ineffective information sharing between two service providers. Concerns also noted insufficient early involvement of approved social workers in Mental Health Act assessments.
Matched on
terms: information, sharing
PFD report
81match
Christiana Pelle
The coroner noted a lack of clear guidance for community district nurses on GP involvement and insufficient systems for sharing information or escalating concerns among various partner agencies and care providers involved in community patient care.
Matched on
terms: information, sharing
HSSIB recommendation
81match
Healthcare provision in prisons
HSSIB recommends that NHS England/Department of Health and Social Care includes within its healthcare IT procurement system specification the need to support interoperability between the operational prison IT systems and any future prison healthcare IT system. This will ensure that information which does not impinge on the confidentiality requirements of either system, relevant to the safety and wellbeing...
Matched on
terms: information, nhs
HSSIB recommendation
81match
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It is recommended that NHSX considers how technology can assist in mitigating nosocomial transmission in the ward environment with regard to: the use of digital communication technologies in assisting with the deployment of staff and the dissemination and circulation of key information the increased use and availability of personal computing devices and electronic health record systems.
Matched on
terms: information, nhs, record
CQC action
81match
Worthing Hospital
The trust must ensure that patient record documents and systems are reviewed to ensure staff have access to patient information that is accessible, accurate and up to date across all electronic or paper-based records.
Matched on
terms: acces, information, record
CQC action
81match
St Richard's Hospital
The trust must ensure that patient record documents and systems are reviewed to ensure staff have access to patient information that is accessible, accurate and up to date across all electronic or paper-based records.
Matched on
terms: acces, information, record
CQC action
81match
Royal Sussex County Hospital
The trust must ensure that patient record documents and systems are reviewed to ensure staff have access to patient information that is accessible, accurate and up to date across all electronic or paper-based records.
Matched on
terms: acces, information, record
CQC action
81match
The Walton Centre
The service should consider how to minimise the impact of patient records being in different formats, to ensure all staff can access information in a timely manner.
Matched on
terms: acces, information, record
Scottish FAI
81match
Mark John Andrew Smith
However, on the basis that more information allows for a greater ability to make a good decision, the SPS and THB/NHS should consider whether to make it a mandatory requirement for nursing staff to check medical records (if they are available) for a prisoner at the reception assessment. (2) Mr Gilmartin has suggested that more information should be...
Matched on
terms: information, nhs, record
Scottish FAI
81match
N
a. There should be greater communication and co-operation between NHST and NHS Grampian (“NHSG”) in relation to the care of patients who are resident in the geographical area of one authority and subject to treatment in a facility run by the other. b. NHSG should make greater efforts to co-operate in Significant Clinical Event Analysis (“SCEA”) inquiries in...
Matched on
terms: information, nhs
Committee recommendation
80match
#12 - Fifty-Third Report - Covid 19: supporting the vulnerable during lockdown
DHSC acknowledged that there are advantages with NHS data systems—such as having large amounts of data—and disadvantages, for example challenges in connecting and using legacy systems.24 We asked NHS Digital what would help to identify patients earlier. NHS Digital told us this would require a technical solution, faster access to GP data would help, while ensuring that the...
Matched on
terms: acces, information, nhs, record
GIRFT recommendation
80match
Cardiology
Trusts must ensure that there is regular clinical validation of coded data, that all relevant clinical information is captured and readily available to coders and that clinical staff are fully aware of the importance of accurate coding, especially that of co-morbidities. a) Coders have full access to clinical record that is easy to view and interrogate. b) Use...
Matched on
terms: acces, information, record
PFD report
77match
Greg Hutchins
The coroner noted a lack of clear purpose and documentation for telephone triage, including no notes, system updates, or staff recollection. There was also no national system for rapid information sharing for patients from outside the local area.
Matched on
terms: information, sharing
Committee recommendation
77match
#182 - 1st Report - Cutting crime: better community sentences
Voluntary sector organisations ârepeatedlyâ told HM Inspector of Probation that they would like direct access to probation case management systems. 345 âAccess to the authority systems OASys and nDelius would put us in a better position for keeping abreast of all those changes as we go alongâ, we heard from Carrie Peters. 346 Rebecca Robson agreed that, for...
Matched on
terms: acces, information, record
Committee recommendation
77match
#35 - Second Report - Long-term funding of adult social care
Barriers to data-sharing between health and social care have been a long-standing challenge, so we particularly welcome the Government’s ambition to have shared care records for all citizens by 2024. It is vital that this ambition becomes a reality. 80 Long-term funding of adult social care The Government should set up pilot schemes for shared care records, co-produced...
Matched on
terms: record, sharing
Committee recommendation
77match
#21 - Require Government to detail progress on Pharmacy First digital product rollout and interoperability.
When responding to this report, we ask that the Government sets out what progress has been made on rolling out the full digital product for the documentation of Pharmacy First consultations, including the percentage of community pharmacies that have fully functioning and interoperable read/write access to patient records.
Matched on
terms: acces, record
HSSIB recommendation
77match
Medication not given: administration of time critical medication in the emergency department
How does your organisation support staff to access information (including information from primary care and specialty teams) about patients’ time critical medications?
Matched on
terms: acces, information
HSSIB recommendation
77match
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you support interoperability of electronic systems to enable effective information sharing across different organisations?
Matched on
terms: information, sharing
HSSIB recommendation
77match
Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)
Making information about service users easily available and accessible across providers to support effective initial engagement and decision making.
Matched on
terms: acces, information