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Missing clinical information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care.

Burnett, SJ; Deelchand, V; Franklin, BD; Moorthy, K; Vincent, C; (2011) Missing clinical information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care. BMC Health Serv Res , 11 , Article 114. 10.1186/1472-6963-11-114. Green open access

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Abstract

In Britain over 39,000 reports were received by the National Patient Safety Agency relating to failures in documentation in 2007 and the UK Health Services Journal estimated in 2008 that over a million hospital outpatient visits each year might take place without the full record available. Despite these high numbers, the impact of missing clinical information has not been investigated for hospital outpatients in the UK.Studies in primary care in the USA have found 13.6% of patient consultations have missing clinical information, with this adversely affecting care in about half of cases, and in Australia 1.8% of medical errors were found to be due to the unavailability of clinical information.Our objectives were to assess the frequency, nature and potential impact on patient care of missing clinical information in NHS hospital outpatients and to assess the principal causes. This is the first study to present such figures for the UK and the first to look at how clinicians respond, including the associated impact on patient care.

Type: Article
Title: Missing clinical information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care.
Location: England
Open access status: An open access version is available from UCL Discovery
DOI: 10.1186/1472-6963-11-114
Publisher version: http://dx.doi.org/10.1186/1472-6963-11-114
Language: English
Additional information: © 2011 Burnett et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. PMCID: PMC3118108
Keywords: Confidence Intervals, Great Britain, Health Records, Personal, Hospitals, Teaching, Humans, Outpatient Clinics, Hospital, Outpatients, Patient Care, Prevalence, Prospective Studies, Referral and Consultation, Risk Factors, State Medicine, Systems Analysis
UCL classification: UCL > School of Life and Medical Sciences
UCL > School of Life and Medical Sciences > Faculty of Life Sciences
UCL > School of Life and Medical Sciences > Faculty of Life Sciences > UCL School of Pharmacy
UCL > School of Life and Medical Sciences > Faculty of Life Sciences > UCL School of Pharmacy > Practice and Policy
URI: http://discovery.ucl.ac.uk/id/eprint/1352335
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