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December 2001 How accurate is record keeping in the
NHS? The importance of accurate record
keeping and its impact on clinical audit has again been highlighted in a
recent report from the Royal College of Surgeons The RCS has just completed a three-year
study into the 3M Capital Hip and has made a series of high-level
recommendations. Three of the
recommendations highlight the importance of Electronic Patient Record systems
in the NHS health system. The Capital Hip System, manufactured by
3M Health Care Ltd, was sold in the UK from 1991 to 1997. Certain designs of the hip exhibited
a higher than usual rate of problems early in their life. The investigation by the Royal
College of Surgeons determined the extent of the problems with the Capital
Hip and make recommendations for improving joint replacement services in the
future. Several issues during the investigation
highlighted the importance of proper record keeping and the poor level of
hospital records in the past.
Specifically, the total number of people who had Capital Hips
implanted was not known. Not all
patients who received a Capital Hip could be traced – 4% or 148 hips. Tracking of patients who received
Capital hips was performed by a very time-consuming search through paper
records. Deficiencies were found
in the detail of records kept:
descriptions, catalogue numbers, and batch details were missing in
many patient records. The report recommended that the level
of patient records be improved and more information be kept on the performance
of hip implants. Specific
recommendations include the collection of data by manufacturers on
performance of their hips, comprehensive information collection is required
for clinical trials of hip designs, a national hip registry should be
established to collect information, and finally surgeons need to ensure that
they record certain information while carrying out all total hip
replacements. The NHS is currently introducing
electronic patient record (EPR) systems for all hospitals over the coming
years. Electronic patient
records and other associated clinical information systems offer a manageable,
time-saving solution for the recommendations mentioned above. EPR systems give both clinicians and
administrators the ability to store and retrieve information about patients
and hospital practice at a very detailed level. For more information about EPR systems
and their effect in the NHS please contact: Michael Green Director Joint Solutions Ltd Longdene House Hedgehog Lane Haslemere, Surrey GU27 2PH Ph. 01428 656 099
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