Ombudsman Rob Behrens comments on the report released today by the Healthcare Investigation Safety Branch (HSIB) on access to critical patient safety information.
The report highlights a case where a patient was misidentified leading clinicians to think a do not attempt cardiopulmonary resuscitation (DNACPR) decision had been made. When the patient went into cardiac arrest, the clinicians did not initiate CPR and sadly the patient died before the mistake was identified. The report explores the factors that impact the ability of staff to access critical patient information at the bedside.
Ombudsman Rob Behrens said:
“Improving and prioritising patient safety must be a top priority. HSIB’s report highlights a tragic case where things have gone wrong in the application of DNACPR, and we need to see meaningful changes to prevent this happening again. Clinical staff should always be able to access accurate, critical patient information so patients get the best possible care.
"This report is a step in the right direction, and I welcome its recommendations, particularly on improving guidance to staff and ensuring patient information can be readily and reliably accessed.”