Records

1
Records Risk

• Liz Price
• Medical and Dental Defence Union of Scotland

2
Less Paper Less Risks?

• Moving down the paperlight
• route may reduce the paper, but does it reduce
  the risks?

3
Risk Management

• What could go wrong?
• What are the chances of it going wrong, its
  impact does it really matter?
• Is there anything you can do about it?
• Whats the cost of getting it right first time V
  the cost of getting it wrong?

4
Paperlight impacts on
? and ?

• the mechanisms by with information is shared
  within the team
• systems processes/increased accessibility
• the quantity and quality of information shared
  within the team
• the mechanisms by which individuals share
  decision-making
• partial/full/systems
• where and how information is stored
• levels of access/subsets of records

5
Record Keeping

• Dated/ Legible / Signed ?
• Methodical / Consistent ?
• Complete Medication History ?
• Do not alter later (unless wrong patient note
  why) ?
• Value of the negative ?
• Avoid abbreviations ?
• Telephone consultations recorded ?
• Sensitivities (BOLD / RED / where?) ?

52 of 200 cases
6
Electronic Records

• Dual systems (not the full picture) ?
• Storing information (what did you store in the
  front pocket?)
• Insurance reports ?
• Living wills ?
• Letters from relatives ?
• Staff records ?
• Shredding
• Retrievable backup ?
• Data verification ?
• Levels of confidentiality
• Patients requesting non-disclosure of info ?
• Limiting access within the team ?
• Consistency of data entry ?
• Will the locum know how to use the system ?

7
What about results?
14 of 200 cases

• What are the risks.?
• 6 risk areas
• How do we measure up.?
• RISK ASSESSMENT
• How can we minimise the risks?

8
Dealing with results
Actions Taken
6
Actions Ordered
5
Results Seen
4
Results Returned
3
Tests Done
2
Tests Ordered
1
9
The Swiss Cheese Model
BMJ 18 March 2000 - James Reason, Professor of
Psychology
10
Risk Management

• What could go wrong?
• What are the chances of it going wrong, its
  impact does it really matter?
• Is there anything you can do about it?
• Whats the cost of getting it right first time V
  the cost of getting it wrong?

11
Rating Probability (Likelihood)
12
Rating Impact (Severity)
Factors
13
Risk Management

• What could go wrong?
• What are the chances of it going wrong, its
  impact does it really matter?
• Is there anything you can do about it?
• Whats the cost of getting it right first time V
  the cost of getting it wrong?

14
Likelihood
5

• Likelihood
• Very Low
• Low
• Medium
• High
• Very High

Severity
5
1

• Severity (Impact)
• Negligible
• Minor
• Significant
• Major
• Catastrophic

1
15

• A practice incident

16
Every member of the team needs to be involved in
the systems to improve quality and reduce risks
17
Risk Management
Good