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You are writing a discharge summary for a patient sent home earlier in the day when you are interrupted by a call from the ward about another patient. You call up the latest results for that patient and then go to review her. In line with good practice, you lock your computer screen while you leave the office for a few minutes.
Some time later, having dealt with several matters on the ward, you return to your desk to complete the discharge summary. You want to include the scan results and go to check them on the computer. When you reactivate the computer the ward patient's results are still there as the last ones you reviewed. You forget that you had called these up and mistakenly assume that the screen shows the results of the patient whose discharge summary you are writing and include them in your report.
A week later the discharged patient is readmitted and you are asked to see him once again. When you read the notes you realise that the summary you had written was inaccurate and included the wrong scan findings. What should you do?
Discharge summaries are an important tool for communicating essential information between the discharging team, patient, GP and other hospital departments. There could be serious consequences for the patient if their future care is based on the wrong information. It comes as no surprise therefore that the GMC advises in paragraph 19 of Good medical practice (2013) that "documents you make (including clinical records) to formally record your work must be clear, accurate and legible."
You may be tempted to just amend the copy of the summary in the hospital records. However, this will not reach all the recipients of the inaccurate document and there will be no explanation of why you have made the changes.
To provide safe patient care you will need to communicate the corrected information to all the relevant parties, explain your mistake and ask for copies of the inaccurate summary to be removed or to be clearly marked as erroneous.
An apology would also be appropriate. As the patient will have had a copy of the incorrect summary it will be important to say sorry personally and explain what has happened and how you will put things right. As with any discussion with a patient, you will need to make a note of it in the clinical records and this will give you an opportunity to document your mistake and how it arose.
The GMC also expects doctors to contribute to the recognition of adverse incidents and to learn from events. You should report the error using your hospital incident reporting system and discuss what has occurred with your educational supervisor and/or consultant. Whenever referring to records or results, whether on screen or on paper, you should take a moment to ensure that you have the correct patient's details in front of you.
This page was correct at publication on . Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.