This is my personal story of a series of random failures in information and communication systems that affected me when I was an inpatient nearly 3 1/2 years ago. I never made a complaint – because really what was the point but if this happens in a (relatively ) well run and respected district hospital, what else happens elsewhere?
In May 2009, I began to suffer episodes of intense upper (Right quadrant) abdominal pain. I was eventually admitted three times over about a period of 4- 5 weeks with further follow up being done in outpatients.
Over that period:
- I went through the admissions procedure three times – asked the same routine questions of tel no, address etc by the same team of admitting nurses three times.
- Clerked in by the same team of drs three times. Only on the last admission did anyone react to the fact I told them about my LBB (NOT MI related!) so that they requested an ECG (perhaps previous requests had been made and ignored/ lost)
- Had to go for CT scan. It was up to me to read the bottle of contrast medium and ask the nurse, “There’s a warning about Metformin here”Nurse: “Oh that’s right, you’re on Metformin aren’t you? I’ll ring the department!” (Contrast media interacts with metformin and can result in acute renal failure) . Nurse came back and said, you haven’t had it for 24 hrs so you ‘should’ be okay”
- When I got back from the scan I asked the nurses to put an interaction warning on my med kardex to say I couldn’t have metformin for another 24 hrs (according to the info I had been given by the US scanners) . Cue the med round at night, nurse said “No metformin for you.” I nod, “Yes drug interaction.” “No, you are NBM”
- Scan results – this is over 24hrs since I was admitted. Ward round, no mass seen and don’t worry its not appendicitis either. (by this point I am in such pain that I need controlled drugs to control it.) . My next question is “Are you sure that is my scan result?” “Yes. why do you ask?” “I had my appendix removed 10 years ago…” “Where are this patient’s notes?” (I was discharged a few hours later with a promise to refer me to the ‘pain dr’.)
- Finally got an appointment with the ‘pain and unusual syndromes dr’ after much contact with his secretary. Arrive at OP to find that my appointment has been cancelled by the consultant. After much negotiation (ie stomping of my feet) I got into see him that day ( but at end of his clinic). Found out that he’d called my home number to get a pre-history and because I hadn’t replied to his answerphone message, he thought I didn’t need his services. On checking of phone numbers we found that the number they had down on my notes wasn’t my home phone number. Remember, I’d only been through the admissions procedure three times and been for a gastroscopy, Barium enema during that period…
- This one is a perpetual grouse for me. I’m diabetic T2 , why is it whenever diabetics are admitted they are suddenly considered too mentally feeble / unreliable to take their own blood sugar and then decide whether they need help or not? I had a bm taken one morning and it had dropped to round about 3.5 mmol/l (48 hrs NBM with IV in situ) . I didn’t think it was too bad but the nurse overruled me and gave me a 500ml bottle of lucozade to drink. I complied and expected to have another bm in a couple of hours. Next one was done about 8hrs later just before I was discharged home…
- The first time I was admitted, I had been nbm for nearly 48 hrs and was told that I should have some breakfast and that I could the n go home. Nurse said she’d be back with it in a few minutes. This was 8.30. By 11.30 she hadn’t returned and I had asked again. By this time I *was* experiencing hypo symptoms, sweating, shakiness … The paper trolley was around so I bought some *ahem* glucose off the trolley and self medicated. When I felt a little better, I wandered off and still recovering from the disturbance in my blood sugar and found a staff nurse to say I’d had a hypo and I’d had some sweets to sort it in lieu of any breakfast… Breakfast was promptly found and then she said I’d better do a blood sugar *rolls eyes*.
I’m mouthy and will ask questions, take things into my own hands, and am a person that will read instructions and look stuff up on the internet. My story of what I consider to be some critical and what should be, avoidable, failures in the information systems is one that didn’t have any particular effect other than make some things harder for me – dealing with the pain (still undiagnosed) , numerous admissions to hospital, dealing with daily life and two SEN children amidst tests and OP apps, didn’t thankfully have any real effect on me but what if I wasn’t the person I am? If these sort of random systemic failures happen to me then what chance does the public have.
Information and communication (both part of the same process) are vital to any sort of care system . If information isn’t shared then it can’t be acted upon, if information isn’t recorded correctly then it cannot affect the subsequent care by any health professional, if information isn’t collected at the appropriate time then the right care can’t happen at the right time and in the right place.