Inaccurate and inaccessible patient records
Failure to maintain easily accessible, up-to-date, and accurate information about patients/service users in care settings.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
87match
F244 - Common information practices shared data and electronic records
There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering the introduction of electronic patient information systems: Patients need to be granted user friendly, real time and retrospective access to read their records, and a facility to enter...
Matched on
terms: patient, record
HSSIB recommendation
86match
Electronic patient record systems – electronic referrals for ongoing care
HSSIB recommends that NHS England/Department of Health and Social Care, in collaboration with relevant Royal Colleges: commissions the development of advice and guidance request and response templates for specialties where these do not exist, including general practice supports effective implementation of template use in practice. This is to support greater standardisation in the electronic clinical information provided when...
Matched on
terms: patient, record
PFD report
85match
Afifa Qaisar
The coroner identified issues with inaccurate drug administration records, unavailability of resuscitation equipment, the patient not being notified to the RMO, delays in platelet transfusions, and a lack of fluid balance charting.
Matched on
terms: inaccurate, patient, record
Committee recommendation
84match
#6 - Fifty-Third Report - Covid 19: supporting the vulnerable during lockdown
Missing or inaccurate telephone numbers in NHS patient records undermined government’s efforts to contact 375,000 people. The contact centre relied on telephone numbers in NHS patient records when calling people to check their needs. Over 20% of the 1.8 million telephone numbers passed to the contact centre from NHS records, for roughly 375,000 people, were missing or found...
Matched on
terms: inaccurate, patient, record
Inquiry recommendation
82match
R20 - Stool records for CDI patients
Health Boards should ensure that where a patient has, or is suspected of having, C. difficile diarrhoea a proper record of the patient’s stools is kept. Health Boards should ensure that there is an appropriate form of charting of stools available to enable nursing staff to provide the date, time, size and nature of the stool. Stool charts...
Matched on
terms: patient, record
Inquiry recommendation
82match
R15 - CDI patient observations records
Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration, oxygen saturation and blood pressure.
Matched on
terms: patient, record
HSSIB recommendation
82match
Electronic patient record (EPR) systems – thematic review
How does your organisation identify requirements for an EPR system to account for organisational and user (patients and staff) needs?
Matched on
terms: patient, record
Inquiry recommendation
82match
R38 - Medical record keeping
Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to good patient care, and that they are routinely audited by senior medical staff.
Matched on
terms: patient, record
HSSIB recommendation
82match
Online prescribing: challenges and opportunities to improve patient safety
HSSIB recommends that the Department of Health and Social Care undertakes a review to explore the options and determine an appropriate mechanism for write access to health records for independent prescribing organisations. This would inform future developments such as the Single Patient Record, improve the currency of patient information held digitally by NHS organisations, and may remove some...
Matched on
terms: patient, 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: patient, record
CQC action
81match
The York Hospital
The trust must ensure that patients records are maintained securely, are accurate, complete, and contemporaneous records maintained in respect of each service user.
Matched on
terms: patient, 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: patient, record
CQC action
81match
Scarborough Hospital
The trust must ensure that patients records are maintained securely, are accurate, complete, and contemporaneous records maintained in respect of each service user.
Matched on
terms: patient, 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: patient, record
LGO / SPSO decision
80match
201508104 - Grampian NHS Board
Mr C complained that an incorrect entry had been placed in his GP records which he had asked the practice to remove or mark 'to be disregarded'. He also complained that the board did not deal with his subsequent complaint in a timely manner. Following investigation, we were of the view that the practice had taken reasonable action...
Matched on
terms: inaccurate, patient, record
Inquiry recommendation
78match
R14 - Patient records compliance audit
Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous patient records. Health Boards should ensure that there is an effective system of audit of patient records, and that there is effective scrutiny of audits by the Board.
Matched on
terms: patient, record
Inquiry recommendation
78match
IBI-4d - Patient Records Audit
Patient Records: Before the end of 2027 there should be a formal audit, publicly reported, of the extent of success of digitisation of patient records in each of the four health jurisdictions of the UK, measuring at least the levels of patient access to their personal records, their ability to identify and correct apparent errors in them, their...
Matched on
terms: patient, record
HSSIB recommendation
78match
Local integrated investigation pilot 2: Incorrect patient details on handover
HSIB recommends that the nursing home implements a mechanism to use care records with the lowest risk of having incorrect personal identification data during interactions with the wider healthcare system.
Matched on
terms: patient, record
HSSIB recommendation
78match
Positive patient identification
HSSIB suggests that integrated care boards assure that where a patient misidentification has occurred, healthcare organisations in their geographical footprints have collaborative processes to learn why and to ensure health records are correctly allocated.
Matched on
terms: patient, record
HSSIB recommendation
78match
Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of...
Organisations can improve patient safety by involving ‘digital experts’ in their electronic patient record system improvement projects. This will support any digital configuration and infrastructure changes required to record person-centred approaches to psychosocial assessments and safety planning.
Matched on
terms: patient, record
Committee recommendation
78match
#1 - Ensure urgent and full implementation of IMMDS review recommendations 6 and 7 on patient records
Without records of which patient has undergone which procedure, or been prescribed which drug, the health system will continue to, in the words of the IMMDS review team, “fly blind”. We recommend that the Government urgently ensures that the accepted recommendations 6 and 7 of the IMMDS review are fully implemented.
Matched on
terms: patient, record
PFD report
77match
Lee Hollman
The coroner identified concerns regarding the maintenance of accurate and updated medical records, specifically relating to medication details. There was also a lack of an effective system for issuing repeat prescriptions and reviewing patients according to guidelines.
Matched on
terms: patient, record
PFD report
77match
Nicos Michael
Inconsistent and incomplete documentation of the patient's allergies across multiple hospital records meant this critical information was not consistently available to staff or shared with the GP. Current medical reporting and computer systems do not adequately ensure allergy information is readily accessible for patient treatment.
Matched on
terms: patient, record
GIRFT recommendation
77match
Anaesthesia and Perioperative Medicine
Mandate a specific dataset which effectively captures the hospital activity and input for the anaesthetic and perioperative medicine team as a priority. a Ensure surgical pathway coding is appropriate, especially concerning admission on an intended day case pathway, to be differentiated from elective inpatient admission. b Investigate the need for inclusion of codes to record perioperative activity. c...
Matched on
terms: patient, record
GIRFT recommendation
77match
Acute and General Medicine
Ensure physicians and clinical coders improve the accuracy of data collection and ensure that all coding is undertaken consistently. a Trusts to provide training on the importance of accurate clinical coding for all physicians at induction. This should specifically highlight the relationship between what is recorded and what is coded. (Ideally, a longer session on clinical coding should...
Matched on
terms: patient, record
CQC action
77match
Royal Victoria Infirmary
The trust must maintain securely an accurate, complete, and contemporaneous record including a record of the care and treatment provided to patients and of decisions taken in relation to the care and treatment provided.
Matched on
terms: patient, record
CQC enforcement action
77match
Warning Notice: Essex Partnership University NHS Foundation Trust
The Care Quality Commission (CQC) carried out unannounced focused inspections of Finchingfield Ward in October and November 2020 due to concerning information regarding safety incidents. Inspectors found that some staff did not follow required actions to maintain patient safety, including inadequate observation practices and issues with record-keeping. CQC served warning notices to the trust to ensure improvements are...
Matched on
terms: patient, record
Committee recommendation
76match
#24 - Fifty-Third Report - Covid 19: supporting the vulnerable during lockdown
The DWP contact centre relied on telephone numbers in NHS patient records to call clinically vulnerable people who had not yet registered their needs. In some 375,000 cases out of the 800,000 people that the contact centre could not get hold of, or over 20% of the 1.8 million people the centre attempted to contact, it was because...
Matched on
terms: inaccurate, patient, record
Committee recommendation
75match
#13 - Thirteenth Report - Initial lessons from the government’s response to the COVID-19 pandemic
The pandemic has again highlighted the role of high-quality data in enabling effective service delivery, monitoring and improvement. For example, due to missing or inaccurate telephone numbers within NHS patient records, the shielding programme was unable to follow-up letters to 375,000 vulnerable people with phone calls. Local authorities, which were passed the details of individuals who could not...
Matched on
terms: inaccurate, patient, record
Inquiry recommendation
74match
R25 - Accessible financial records
The records kept must be easy to manage by staff and easily comprehensible to others, including people with learning disabilities and autistic people, carers and relatives.
Matched on
terms: record
HSSIB recommendation
74match
Local integrated investigation pilot 1: Incorrect patient identification
The Ambulance Trust is designing a confirmation checkpoint, which will be included in the electronic patient record for ambulance crews to confirm the correct identification.
Matched on
terms: patient, record
GIRFT recommendation
74match
Mental Health Rehabilitation
1.2 All mental health trusts, health commissioners and social care commissioners, as well as housing partners, should robustly record and monitor all OPPs and report this on a minimum quarterly basis. a Confirm a local definition of OPPs and track numbers in advance of the NHS England and NHS Improvement developed definition being agreed in 2022. b Include...
Matched on
terms: patient, record
PFD report
73match
Daniel Williams
The coroner noted deficiencies in staff training regarding record keeping and communication, and the absence of clear guidance for checking patients and rooms for potential self-harm items. Concerns were also raised about the lack of a single summary sheet in patient notes and the balance between holistic care and patient safety.
Matched on
terms: patient, record
PFD report
73match
Zeeyad Hamadi
The coroner noted a lack of routine patient weighing, poor medical record keeping, and confusion regarding the funding and logistical arrangements for a prisoner seeking private healthcare outside the prison, further complicated by a lack of formal policy.
Matched on
terms: patient, record
PFD report
73match
Charles Bradley
The coroner noted inadequate and ineffective record-keeping and communications at Arrowe Park Hospital, evidenced by issues with patient transfer information and inconsistent documentation of a patient's fall.
Matched on
terms: patient, record
PFD report
73match
Gary Bradshaw
The coroner noted delays in diagnosis, issues with incomplete blood test reporting, and medication prescribed before test results were known. Concerns also included an insufficient threshold for flagging critical blood-calcium levels, inadequate record-keeping, and apparent gaps in patient escalation to intensive care.
Matched on
terms: patient, record
Inquiry recommendation
73match
R19 - ICN instructions recorded
Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in the patient notes and are included in care planning for the patient.
Matched on
terms: patient, record
Inquiry recommendation
73match
COVID-M3.4 - Data Systems for High-Risk Individuals
The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in a future pandemic. This should include action to improve health data systems and patient record-keeping by: improving patient...
Matched on
terms: patient, record
HSSIB recommendation
73match
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: patient, record
GIRFT recommendation
73match
Hospital Dentistry
Primary and secondary diagnoses (comorbidities) should be recorded for all activity in an outpatient setting, in order to quality assure the services being provided. a NHSE Dental Commissioning to consider with trusts how this data can be recorded with as little resource input as possible in SUS, and should consider agreeing a data quality improvement plan to guide...
Matched on
terms: patient, record
GIRFT recommendation
73match
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: patient, record
CQC action
73match
Royal Preston Hospital
The service must ensure that staff complete patient records accurately and in a timely manner.
Matched on
terms: patient, record
Scottish FAI
73match
Maureen Smyth
In my view is essential that such reports are promptly filed in the patients medical records, and that a dated entry (perhaps by use of a stamp) indicating receipt of the report is made in the running clinical notes within the records, so that any doctor looking at the clinical notes will be alerted to the fact that...
Matched on
terms: patient, record
Scottish FAI
73match
Judith Laing
The need for a review of procedure at Inverclyde Royal Hospital on how amended reports/results/findings are introduced into a patient’s medical records, how the existence of an amended report/result/finding or opinion is highlighted in the patient’s medical records, and how any amendments are brought to the immediate attention of those treating a patient. I consider there should be...
Matched on
terms: patient, record
Scottish FAI
73match
J.K. Sweeney, L. Sweeney, E.P. McQuade, S.C. Tait, G.M. Ewing and J. Morton
5.1 Doctors generally, and general practitioners in particular, should take steps to ensure that medical notes are made and kept in such a way as to maximise their ability to identify repeated episodes of loss of consciousness, loss of or altered awareness, in the case of patients who are or may become drivers. 5.2 When a doctor is...
Matched on
terms: patient, record
CQC enforcement action
73match
Warning Notice: Royal United Hospital Bath NHS Trust
The Care Quality Commission issued a formal warning notice to Royal United Hospital Bath NHS Trust. This action followed an unannounced inspection in June, which found the hospital was failing to meet five national standards, including those related to patient records. The warning requires the trust to make urgent improvements to ensure accurate patient record-keeping by 29 November...
Matched on
terms: patient, record
Inquiry recommendation
73match
R22 - Relative discussions recorded
Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant to the patient’s continuing care is recorded in the patient’s notes to ensure that those caring for the patient are aware of the information given.
Matched on
terms: patient, record
LGO / SPSO decision
72match
21-018-569c - The Coach House Residential Home (21 018 569c)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or the Trust. The identified faults caused avoidable distress...
Matched on
terms: patient, record
LGO / SPSO decision
72match
21-018-569a - Norfolk & Suffolk NHS Foundation Trust (21 018 569a)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or the Trust. The identified faults caused avoidable distress...
Matched on
terms: patient, record
CQC action
71match
Russells Hall Hospital
The trust must ensure that they maintain an accurate, complete and contemporaneous record in respect of each service user, including a record of care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.
Matched on
terms: record