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Topic # 198591 15-Jul-2016 10:16
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I'm in the midst of trying to get a "minor" paperwork error sorted -  at this stage it's resulted in no harm, but this drives me nuts.

 

I'm advocating for a patient with a serious but treatable condition.  All specialists have been wonderful, thorough.  At hospital pre-admission (a few days before surgery) after meeting with registrar, anaesthetist, then  - with a nurse doing BPs, weighing, she's reading to herself some notes from the DHB admission form on screen out loud when my ears prick up, as there were two aspects to their records on diagnosis which weren't consistent with notes from pathology and radiology.  One I'd assumed to be a simple typo (one letter wrong on a commonly used acronym perhaps on some record, then "expanded" back into a wrong full description).  I don't "think" I'm right here - I'm absolutely 100% sure I'm right, specific biomarkers were identified which effectively rule out the diagnosis they've got on their paperwork.   The other possible "mistake" I put down at that time to normal margin of error / variation between estimates from different medical imaging techniques, it was a little higher than expected, I've read research data indicating say typical 20% variance, this was about 50%, which is possible but at the high end.  But WTF - I've now looked back and they got that wrong too - referring back to the actual radiology notes / measurements and it falls back within the 20% margin of error.  I have little doubt what happened here is that someone has typed in notes from another patient into this patient's records. Someone somewhere has had two sets of records open on their desk (or computer desktop). If they've also transposed their records the other way around, then hmmmm.  

 

Now all this is actually so obvious, it's easily sorted...  I asked the nurse at pre-admission to sort it, yup.  I mentioned it to the registrar before the patient was wheeled in to surgery, yup.  The operation has been completed, the patient is home, doing fine.  I have had a quick look at the records / discharge notes, and sure enough nothing has changed, the records still show the incorrect diagnosis.

 

This actually does have potential implications for follow-up treatment.  Specialists - no, they'll refer back to their notes.  Generalists and admin - yes.  So far what I've told them has fallen on deaf ears, they assume I'm an interfering know-it-all idiot on some kind of a mission.  Well I absolutely am on a mission - there is no way I want that incorrect diagnostic information popping up on this patient's records ever again. The records must be corrected. Their business not mine, but they better be 100% sure they haven't got this stuffed up with another patient. It could lead to a future mistake - and that could actually have fatal consequences.

 

I really wanted and tried to get this sorted with minimum fuss.  Their business again - to a point - how they go about looking at preventing rubbish like this happening.  I've been at this patient's side at every step and for every appointment and procedure except theatre itself. They check and counter-check (probably hundreds of times now) patient ID, DOB, address etc, yet here they've made a serious mistake which could have the same consequences (wrong treatment), I put clear evidence of this in front of them, but nothing happens in a hurry it seems, in fact I'm yet to be convinced anything will happen at all.  Hell will have seen no fury as I will unleash if they do not get this sorted.


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  Reply # 1592988 15-Jul-2016 11:05
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FWIW, the patient supposedly owns the data, and is therefore entitled to request a copy of it, and to make corrections to it. I suggest that your mission should go via the complaints process of the DHB. If it's like ours, they will audit and track the complaint, and have someone follow it through until it is corrected, and report back to the patient about the outcome.

 

The clinicians treating the patient will have no normal process available to them to get the records corrected.

 

 


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  Reply # 1593010 15-Jul-2016 11:34
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Yep if you (on behalf of the patient) have tried its time to make a complaint.  Watch how fast everyone moves at that point.

 

 

 

Implications could affect travel insurance claims, health insurance in the future all sorts of things..


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  Reply # 1593155 15-Jul-2016 13:45

What you describe certainly warrants a complaint to management. But, if the patient is capable, then the complaint should come from him/her. I guess you will have discussed your concerns with the patient. You mention that you are the patients advocate and, by that, I presume you are not a relative. If you are to present the complaint, then you must have the legal right to represent the patients views, such as "Power of Attorney". You also have to remember that "The Privacy Act" may be invoked unless you can prove to be a legal representative of the patient. I would also point out that the nurse who, unwittingly, let you hear and see the patients notes was, herself, lax with privacy considerations.

 

Having said all that, I wish you luck. These things should not happen, but when they do, they should be put right.  It is going to take some time before resolution, however.




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  Reply # 1593401 15-Jul-2016 21:54
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idle:

 

What you describe certainly warrants a complaint to management. But, if the patient is capable, then the complaint should come from him/her. I guess you will have discussed your concerns with the patient. You mention that you are the patients advocate and, by that, I presume you are not a relative. If you are to present the complaint, then you must have the legal right to represent the patients views, such as "Power of Attorney". You also have to remember that "The Privacy Act" may be invoked unless you can prove to be a legal representative of the patient. I would also point out that the nurse who, unwittingly, let you hear and see the patients notes was, herself, lax with privacy considerations.

 

Having said all that, I wish you luck. These things should not happen, but when they do, they should be put right.  It is going to take some time before resolution, however.

 

 

The patient is a relative, I'm advocating and supporting - not "taking over".  The nurse wasn't lax - the patient wishes all records / patient information to be disclosed to me, she was just commenting on admission notes, the mistake was not hers. Yup - if a formal complaint is laid, it will be signed by the patient.  I'd prefer if that process happened without a fuss - as quickly as possible - but it hasn't.  There's a possibility that a more serious error has been made - if the patient I'm advocating for has had (part of) their record mixed up with another person's records, and if that's gone both ways, then that other patient could be in some more serious trouble as a result. 

 

 


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  Reply # 1593413 15-Jul-2016 22:37
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When you understaff and overwork and underpay ie may fewer people to the jobs of many with no extra renumeration - this is what you get. And what more, if said people take leave, no one else would be employed to cover - the work just piles up and waits for them when they return from leave.

 

While the DHB CEO makes and takes more and more every year for meeting all targets that people slave out on (i use slave because they are basically doing work for free).

 

Seems normal work condition in NZ. Not in Australia.

 

I'd say investigate this path before blaming the clerks.




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  Reply # 1593446 16-Jul-2016 09:31
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joker97:

 

When you understaff and overwork and underpay ie may fewer people to the jobs of many with no extra renumeration - this is what you get. And what more, if said people take leave, no one else would be employed to cover - the work just piles up and waits for them when they return from leave.

 

While the DHB CEO makes and takes more and more every year for meeting all targets that people slave out on (i use slave because they are basically doing work for free).

 

Seems normal work condition in NZ. Not in Australia.

 

I'd say investigate this path before blaming the clerks.

 

 

 

 

I don't think this can be blamed on funding, it's a procedural / paperwork error "hole" in a system, and while mistakes get made - then from some of the replies, getting the mistake corrected looks like it's going to cost time (and money) for the DHB.

 

It is quite serious as either:

 

A patient was taken into theatre with incorrect diagnosis written on clinical notes.  That might have affected how the operation was carried out - I very much doubt it and don't know enough about how the surgeon refers to notes in theatre - but it is possible.

 

A patient was taken into theatre with a changed diagnosis, without being properly informed of that changed diagnosis.  Being told something by a nurse is not being properly informed.

 

 


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  Reply # 1593463 16-Jul-2016 09:45
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It should be easily fixable.

Contact patient affairs or the consultant involved with most recent admission can lok at the notes , make changed and perhaps write a clarifying letter. Another option is to go to your relatives GP ideally with your relative and ask if they could write a letter to the relevant consultant (GPs get copies of letters)

These errors do come up , like in any organization and there will be systems to correct errors.




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  Reply # 1599625 27-Jul-2016 16:38
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Fixed (I think).  It was a typo - not a changed diagnosis or records inadvertently swapped with another patient.

 

Someone finally "got" that I did understand the pathology report, I led them through that, and they agreed that a mistake had been made.  They agreed that it would be a good idea that we should pull the full hospital records - no hurry on that though.  Unbelievably, someone else (possibly - it may have been the same person) made another mistake in simplified notes given to the patient - they'd recorded a result for a test they haven't done. This better be the last "WTF" moment - or I'm going to need medication.

 

 


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  Reply # 1599653 27-Jul-2016 18:38
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Well sounds like the tip of the tip of the tip of an iceberg continent

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