• Run by a team at NHS Lothian.
  • The project ran from October 2008 until the end of 2013.
  • The project aimed to create safe and reliable systems for managing the flow of information about patients, ensuring that all the necessary information about patients was available to staff working in outpatient clinics.
  • The team established that multiple sets of notes and duplicate patient registrations were significant problems, and focused on rectifying these.

A team at NHS Lothian worked on a project to create safe and reliable systems for managing the flow of information about patients. They wanted to ensure that all relevant and necessary clinical information was available to staff working in outpatient clinics. Results were impressive, with errors in records reduced by over 90%.

The team identified that many patients had multiple sets of case notes, plus there was an issue with duplicate registrations on the patient administration system. This contributed to a lack of information in outpatient clinics, which negatively impacted on patient safety.

The team used various techniques to analyse systems and diagnose issues, including data, error and task analysis.

The priority area was defined as reduction of duplicate patient registrations. The team developed a core data set and reduced duplicate entries to an acceptable level. They also introduced monitoring to minimise new duplicates.

Registration errors fell significantly, with duplicate registrations reaching their lowest level. Correct registrations rose from 74% in April 2008, to a consistent 95% since May 2010.

Learning points from phase one

  • Changing the system to tackle the problem before it happens builds capacity to tackle other issues.
  • The more people involved in a process the more chance there is for error.
  • People are enthusiastic and acknowledge that the Safer Clinical Systems approach has brought something they would not have otherwise tried.
  • A major step forward has been the awareness of the administrative staff that they have a direct impact on patient safety. 

Further reading

Research report

Safer Clinical Systems: Evaluation findings

December 2014

Lessons from the second phase of the Safer Clinical Systems programme.

About this programme

Programme

Safer Clinical Systems

A programme that ran in two phases from 2008 to 2013. It helped health care teams to proactively...

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