MNSI has investigated a number of patient safety events where an incomplete set of observations generated an early warning score (EWS) via an electronic patient record (EPR) system. It was not always apparent to the user that the score was based on an incomplete set of observations and, in some circumstances, led to delayed escalation in patient care. To prevent future safety events of this nature in the future, it is worth considering the below questions:
- Does your EPR system generate an EWS even if the observations entered are not a complete set (e.g. only pulse and BP have been entered)?
- Does your EPR system alert you that an EWS is based on an incomplete set of observations and remind the user to complete all the observations?
How can you enable staff to complete all observations and ensure they generate an EWS correctly?
This was first published in the Stakeholder Bulletin: Sept 2024 - Edition
Related news
Safety Spotlight: Patient Ethnicity Data Collection
MNSI has found that inaccurate or missing recordings of a woman’s ethnicity have impacted her subsequent pathway of care.
Read the full article
Safety Spotlight: Maternal Deaths in the first trimester from Venous Thromboembolism (VTE)
MNSI has undertaken investigations of maternal deaths in the first trimester from venous thromboembolism (VTE)
Read the full article
Safety Spotlight: Changes to the MNSI investigation report template
On 1st April 2024, six months after the transition to being hosted by the CQC, MNSI changed their investigation reports and process.
Read the full article
NEW WEBINAR SERIES: Exploring learnings from MNSI safety investigations
We are starting a new series of webinars in 2025 which will explore learnings and thematic analysis from our safety investigations.
Read the full article