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At the heart of general practice since 1960

Man hands in patient's lost notes and says he had fun reading them

Three GPs share their approach to a practical problem

Three GPs share their approach to a practical problem

Case history

You are out doing a house call and a bundle of papers falls out of a patient's medical records that you are carrying. You do not realise they are missing until another patient hands them into the surgery a few hours later. He hands them over to the receptionist, laughing that the papers proved interesting reading as he knows the patient very well. He can't wait to tell her what happened and how he read all about her medical history. What do you do?

Dr Elizabeth Scott

This is a heartsink situation. It is also what I pay my medical insurers for and I would ring them at once. Subject to their advice, I don't think I would have any alternative but to visit the patient whose notes I had lost, confess the whole business, apologise sincerely and explain how I wanted to kick myself but accepted that the damage was done.

If the patient was not in, I would phone them as soon as possible. I would not leave messages with relatives, I would put it to the patient direct. I would also tell them I was going to try to stop the finder spreading their knowledge any further.

Then I would visit the patient who found the notes, repeat my self-castigation, thank him for handing in the notes, stress their confidentiality and beg him not to discuss them with anyone at all. I would talk to him about what he would feel like if it had been his notes found by someone else.

To both patients I would stress that this was a horrible accident that had never happened before and I would make sure it never happened again, and say clearly that if either or both of them felt they should change their doctor or complain formally they should do so. If they seemed likely to I would ring my PCT and tell them about it too.

Otherwise I would leave it to settle and be extremely polite to both patients in future. If they wished it, I would bring them together in my surgery and grovel once more and try to help them reach an accommodation. I would explain the situation to my partners and staff and take steps to ensure that, in future, all notes were secured in folders.

I am glad this has never happened to me. The thought of it sends shivers down my spine. However as a medical student I once worked in a closed door ward in an old Victorian mental institution. I was given a huge bunch of keys that constantly slid out of my pocket both in the ward and in the grounds. The patients were very good at bringing them back to me. Looking back on it I do not know why most of them were there. Clearly they were better with keys than I was.

Dr Rodger Charlton

You might say I should have been more careful but it could happen to any of us. Yes, I should fill in a significant event analysis form and discuss it at a practice meeting to decide how it might be prevented in the future. The problem is that it has happened and two people need to be contacted; the person who returned the notes and the patient whose notes they were.

Prior to this it is important to establish exactly what the person who found the notes said to the receptionist and to look at the notes to see what has been written about the patient.

It is likely that the person who found the notes is also a patient, as the notes fell out near his house and so hopefully the GP may already know them. It is important to make contact as soon as possible and thank him for taking the trouble to return the records. Ask if you can discuss with him his wish to tell the patient concerned all about the records he has read.

Hopefully, he was just joking with the receptionist. I anticipate he would reconsider if I make him aware that the notes are confidential and that disclosing their content may be harmful to the patient, the doctor and the practice. After all this is a genuine accident and no one would like their personal details made public. This may resolve a potentially difficult situation and prior to seeing the patient it would be important to ask my defence organisation what to do and say.

When you meet the patient you need to explain what has happened and apologise and describe what measures you are taking to stop it happening again – for instance carrying records in a briefcase. You might also consider a three-way meeting with the person who returned the records and the patient whose notes they are. Above all, make sure it does not happen again!

Dr Iain Mclean

Accidents like this happen to everyone from time to time. It is typical bad luck that the person finding the information is neither responsible nor sensible.

The basic rules of an error where confidentiality has been breached are: apologise profusely, repeatedly and to all involved; express gratitude for everyone's positive actions or attitudes; spell out simply and clearly the gravity of confidentiality and the consequences of breaches; use the accident for learning.

First contact the patient whose notes have been lost. Explain why you needed the notes with you, how they were lost, what was in them and how they were returned. Apologise. Offer to review the incident with the patient in the near future.

Next contact the jovial finder of the notes. Be very clear that you and the practice are grateful for their safe return and explain why such details are required on house calls. Apologise for any inconvenience caused and explain that you and the practice will review this as a critical incident with a thorough investigation involving legal advisers and the health board.

Advise him that the notes are marked confidential and any breach of that confidentiality could leave him and the practice open to prosecution. If he knows some of the contents he should respect the patient's confidentiality. His appropriate action would be expected by the practice and the patient. It might be worth discussing how he would feel if it had been his notes that were lost. An offer to update him on actions taken might prove helpful.

Record everyone's responses and discuss the issue with the whole practice and seek advice on prevention. Tell your defence organisation immediately. Use the report to them as part of critical events analysis, complaints, revalidation and reaccreditation.

Accidents and cock-ups happen but if we deal with them sensibly, promptly and pleasantly the damage can be limited. It is just a pity that in our current culture huge time and effort needs to be expended for an event like this. A previous generation might have dealt with this dilemma in short order by telling the finder his comments were stupid and wrong. Progress can be a funny thing.

What does this incident teach us?

Learning checklist

Taking records on visits

  • What information might we need during any consultation? Can the computer print out a summary?
  • If the practice is fully computerised does the Lloyd George folder need to be taken out of the building at all?
  • What are the advantages or disadvantages of using a handheld device or portable PC to download records to take on visits?
  • If you need to phone the surgery for further information how will you protect confidentiality if other relatives are present?
  • If you need to admit the patient should you send the summary sheet as part of your letter? What if it contains third party information or information that might cause the patient distress?
  • What are the implications of leaving records at a patient's house by mistake?
  • How will you make a full and accurate record of the consultation?
  • What precautions should you take if you leave notes unattended in the car?
  • What problems might you encounter out of hours?

Safeguarding patient information

  • The practice's confidentiality policy should be clear and regularly reviewed
  • Staff contracts should cover the importance of safeguarding patient confidentiality; breaches should normally result in dismissal
  • The policy should include checking the bona fides of anyone requesting information by phone or otherwise
  • Patient consent should be obtained to release any information to third parties
  • Where patients are allowed to view their own records (for example on screen) breaches can occur – if the wrong record is accessed, the last patient's record is still on screen or if a third party is in the room
  • Accidental breaches can occur when discussions are overheard, for example in reception, if doors are left open or if tradesmen are working in the building
  • Computer passwords should not be obvious and should be changed regularly. Clinical computers should be logged out immediately after use, including in the consulting room
  • Patients and other members of the public should not be able to get into areas where records can be accessedBreaches of confidentiality
  • A breach of confidentiality is a significant event and an opportunity to improve performance
  • The cause may be an individual's mistake or negligence, a systems failure, or a freak accident
  • Disciplinary action may be appropriate if an employee is the cause
  • Tell the patient, explain and apologise. Patients often say their main concern is to ensure it doesn't happen again
  • Contact your defence organisation even if the patient appears to accept your apology; legal action or a letter from the GMC may yet follow

Melanie Wynne-Jones is a GP in Marple, Cheshire

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