Background
Methods
Design
Setting
Assessment of missing information
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Past medical history
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Referral letter/other specialty letter
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Discharge summary
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Current medication
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Allergies
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Radiology/imaging results
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Diagnostic test results
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Procedure notes/anaesthetic record
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Electrocardiogram (ECG) report
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Blood laboratory results
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Outpatient medical records/last clinic letter
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What information was required, but missing (test results, images, referral letter etc)
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Whether or not they relied on the patient for any of the clinical information that was missing
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Whether they made a clinical decision without the information
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Whether or not the patient required another appointment because the information was missing
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The impact on patient care (delay in management, cancellation of procedure etc) as judged by the doctor using a four point scale (none, minor, moderate, severe)
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The potential risk of harm to the patient as judged by the doctor using a five point scale (no threat, minor, moderate, potential adverse event, potential serious adverse event)
Sample
Interviews to explore the causes of missing information
1. Institutional context | • Economic and regulatory context |
2. Organisational and management factors | • Financial resources and constraints |
• Organisational structure | |
• Policy standards and goals | |
• Safety culture and priorities | |
3. Work environment | •Staffing levels and skills mix • Workload and shift patterns • Design, availability, and maintenance of equipment • Administrative and managerial support |
4. Team factors | • Verbal communication • Written communication • Supervision and seeking help • Team structure |
5. Individual (staff) factors | • Knowledge and skills • Motivation Physical and mental health |
6. Task factors | • Task design and clarity of structure • Availability and use of protocols • Availability and accuracy of test results |
7. Patient characteristics | • Condition (complexity and seriousness) • Language and communication • Personality and social factors |
Results
The prevalence of missing information in surgical outpatient clinics
Organisation | Total number of patients in the sample | Records unavailable (percentage of all patients) | Confidence intervals | Number of patients with missing information (percentage of all patients) | Confidence intervals |
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A | 411 | 1 (0.2%) | 0 to 0.7% | 18 (4%) | 2.4% to 6.4% |
E | 423 | 3 (0.7%) | 0 to 1.5% | 113 (27%) | 22.5% to 31% |
G | 327 | 14 (4.3%) | 2.1% to 6.5% | 44 (13%) | 9.8% to 17.1% |
TOTAL | 1161 | 18 (1.5%) | 0.8% to 2.3% | 175 (15%) | 13% to 17.1% |
Type of missing information
Impact on patient care
System failures analysis
Quote reference | Quote and participant reference |
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1 |
"...where the patient needs either a biopsy, maybe they need some form of staging scan, may need something else, and frankly it, you want everything lined up in the right order, and organisationally, that can be logistically very difficult." Surgeon, organisation E
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2 |
" Computers aren't in every room ... we have a computer in the nurses' station, which is quite a busy area just with you trying to get results" Outpatient nurse, organisation E
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3 |
"I have to say one thing is operating notes. from previous operations are sometimes very important and I find it hard in this hospital sometimes to find these. And the problem is maybe I don't know where they are but I have the feeling they are handwritten notes" Surgeon, organisation A
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4 |
"Some of the doctors forget their password or they haven't got a password so they can't always access the system... the x-ray system it's a different password" Outpatient nurse, organisation E
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The difficulties of aligning a patient's complex pathway ensuring that all tests are completed and reported before they return for their follow up appointment (Table 3 quote 1).
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Across all organisations the problems of finding paper based medical records at short notice was described as a particular problem for urgent appointments, re-bookings and waiting list initiative clinics. This was exacerbated by the proliferation of unstandardised forms for the ordering of different types of test.
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Hospital mergers have brought a number of organisational problems including patients having multiple hospital numbers.
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Problems with paper systems were wide ranging including poor storage facilities in offices and clinics meaning medical records were stored on the floor, to problems with medical records tracking. Poorly fixed folders were cited by staff in two organisations with 'fat folders' for sick patients often falling apart.
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Problems with computer systems included the design of the software, the age and availability of terminals, problems with passwords and logins required to access multiple systems. Old technology meant that some surgeons could not view electronic images from scans and X-rays during an appointment because they took too long to load. Some clinics did not have enough terminals for the doctors to access information during the clinic (Table 3 quote 2).
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Running both paper and computer systems in parallel was given as a problem in all three organisations with staff not knowing where to look for information (Table 3 quote 3).
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In all three organisations problems were experienced with temporary staff or staff covering shifts and being unfamiliar with the local systems. This led to problems with them being unable to find information when required, not having access to certain computer systems or filling in forms wrongly (Table 3 quote 4).
Limitations
Extrapolation of the findings across the United Kingdom the results for the UK
Percentages found in this study | Estimated annual numbers of patients if study findings are applied to: | |
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General surgery outpatients (n = 4.4 million) | All outpatient attendances (n = 66 million) | |
1.5% missing medical records | 66,300 | 991,300 |
15% missing clinical information | 663,000 | 9,913,000 |
4.7% impact on patient care | 207,700 | 3,106,000 |
1.7% new appointment booked | 75,150 | 1,124,000 |
3.2% decision without information | 141,500 | 2,115,000 |
3% risk of harm | 132,600 | 1,983,000 |