Alert (Patient)
Alert (Patient)
Target Audience
All Staff
Appendices
1.0 Alerts Types 13
2.0 Patient Alert Change Request form 18
3.0 Information Help-Desk Alerts Notification Guide 19
Alerts - An electronic flag that is applied to a patient’s electronic record to highlight vitally important
clinical, social or safety factors that may need to be taken into account for individual patients. These
falls into four categories:
1. Clinical Alerts - Ensure any allergies, sensitivities or significant clinical patient information is
immediately noticeable. Also patients subject to Community Treatment Orders, Mental Health
Act detentions, etc.
2. Administrative Alerts - Make staff aware of any special requirements or patient
circumstances e.g. Impaired Hearing, disabilities, CPA status, etc. and inform users of any
historical alerts. These also ensure that staff are aware of patients whose capacity to give
informed consent diminishes as a result of their condition.
3. Staff and Public Safety Alerts - Highlight safety/security issues. These generally relate to
the risk of aggression or violence, ownership of weapons, sexually inappropriate behaviour,
risks from known patient associates, police alerts, registration on the sex offenders register,
etc. These can also relate to environmental factors such as the presence of a large dog at the
property or a high crime area.
4. Safeguarding - these link to potential risks of harm to the patient or an individual linked to
the patient. The also include where a child has been placed on a Child Protection Plan; this
alert may appear on the child’s records as well as the parents (if known to the Trust).
Patient Administration System (PAS) - An electronic patient administration system which records
the patient's demographics (e.g. name, home address, date of birth) and details all patient contact
with the Trust recording clinical correspondence, clinical information etc.
1.0 Introduction
Black Country Partnership NHS Foundation Trust recognise that the use of Patient
Alerts can improve patient care and the safety of staff and other members of the
public by highlighting vitally important clinical, social or safety factors that may need
to be taken into account for individual patients.
Electronic systems within the Trust allow electronic alerts to be added to patients’
records, and these alerts appear at many transaction points within the system. PAS
alerts are only one of a number of potential sources of information relevant to clinical,
social or safety factors. Other important sources of information that should be taken
into consideration are (although this list is not exclusive):
Referral information
Hand- written records
Verbal questioning and confirmation of alerts/allergies etc. from a patient/family
or carers
This Policy describes how the Alert functionality will be utilised as method of
highlighting a potential problem with or some important information about a patient to
health professional and other members of staff.
2.0 Purpose
The purpose of this policy is to ensure that patient alerts are applied as appropriate
to a patient record with a clear process for reviewing and managing active alerts.
Additionally it aims to provide a process for creating new alerts and alert categories.
3.0 Objectives
Ensure that staff are aware of their responsibilities for the use of patient alerts
Make clear the standards for managing alerts on clinical information systems
Outline clear processes for monitoring compliance
Ensure that staff receive appropriate training to their role
4.0 Process
Patient Alerts will be managed centrally by the Business Intelligence Department;
they will be responsible for adding and closing alerts on the PAS and the generation
and issue of monthly reports.
Requests to add an Alert Type are to be made to the Information Help-desk, the
Patient Alert Change Request form (Appendix 2) must be completed. The Business
Intelligence Department will then present the form to the Information Governance
Steering Group for approval. The Information Help-desk will confirm the outcome of
the IGSG to the requester. If the Alert Type is required for an immediate alert a
Version 1.0 October 2016 4
Patient Alert Policy
temporary alert will be created with an existing Alert Type which is the nearest match
to the Alert; if the new alert is approved the existing Alert will be updated, if the alert
is not approved then the temporary alert is made permanent.
Where a ‘Legacy Alert’ is raised the Alert Content will be standardised with the
following information:
- Alert Type
- Date alert was raised
- Date alert was closed
The need for the alert is notified to the Information Helpdesk via the IT Services
Desk; http://fusion.smhsct.local/ (see Appendix 3 for the step by step access guide).
When notifying the Information Helpdesk of the alert you must ensure you include the
following information:
- Alert Type
- Alert Content (text to be included within the Alert Notes)
- Removal Date (if known) or if the Alert is permanent.
- Patient identifier; this can be the NHS Number and/or OASIS number
Once received the Information Helpdesk will add the Alert within 24 hours (except
weekends) and confirm to the requester once the Alert is active.
Where the Alert requested does not fall within the Alert Types given within this policy
the Information Helpdesk will refer the alert to the Information Governance Manager
for review and possible discussion with the Information Governance Steering Group.
Any risks will be raised whilst awaiting approval from the IGSG.
Notification is required to confirm that the Alert is still valid; if the Alert is no longer
valid the Alert must be updated or removed.
Where the Alert Type remains valid but the Alert Content is required to be updated;
the updated Alert Content is to be forwarded to the Information Help-desk to be
amended. Once received the Information Help-desk has 48 hours to complete the
update.
Once these alerts are placed onto the system there is review or end date required for
the Alert.
Staff must consult the PAS along with the manual records when reviewing Alerts
prior to contact with the patient.
Various regulations are made under the Act, which have the same scope, many of
these evolving from European Directives, which enables the potential to achieve
clear and uniform standards.
Records Management Code of Practice for Health and Social Care 2016
A guide to be used in relation to the practice of managing records. This Code is
relevant to organisations who work within, or under contract to NHS organisations in
England. This also includes public health functions in Local Authorities and Adult
Social Care where there is joint care provided within the NHS.
The Code is based on current legal requirements and professional best practice. It
will help organisations to implement the recommendations of the Mid Staffordshire
6.3 References
Essence of Care Benchmarking for Record Keeping
NHSLA Risk Management Standard 1.8
Data Protection Act (DPA) 1998 plus the Information Commissioner’s Office
(ICO) guidance on the DPA and use of violent warning markers.
Health and Safety at Work Act 1974
Information Governance Toolkit
Information Responsible - Requests for new Clinical and Administrative Alerts will be sent for consideration and approval to the Records Management
Governance Steering Sub Group who will in turn report their decision to the Information Governance Steering Group (IGSG). For non-clinical
Group alerts the IGSG will be responsible for approving the Alert
Group Quality and Monitoring - Monitor the management of patient alerts on clinical information systems within their group. Membership is representative
Safety Groups of the group as a whole multi-disciplinary in nature, with a mix of representatives from each of the service areas,
professional leads, practice development professionals and representatives from clinical sub-groups
- Receive the results and recommendations of all completed clinical audits
- Monitor any subsequent actions plans to completion
- Authorise documentation to be used within the group
Quality and Safety Scrutiny and - Oversee the implementation of a systematic and consistent approach to the management of patient alerts on clinical
Steering Group Performance information systems. The Group is chaired by the Medical Director and reports progress to the Executive Committee
- Review the annual Patient Alert Clinical and Quality Audit report
- Approve the addition of new categories and alerts for clinical information systems
Trust Board Strategic - Strategic overview and final responsibility for overseeing this policy in the Trust. This includes meeting legal responsibilities
Overview and for the adoption of internal and external governance requirements
Medical Director Executive Lead - Responsibility for this policy has been delegated by the Chief Executive to the Director of Medicine who is responsible for
ensuring a systematic and consistent approach to the management of patient alerts on clinical information systems across
the organisation
Chief Executive Accountable - Ensure that this policy is implemented within the Trust. Operational responsibility has been delegated
8.0 Training
What key elements will be Where How will they be Who will Group/Committee Group/Committee Evidence
How
monitored? described in monitored? undertake this that will receive and to ensure actions this has
Frequently?
(measurable policy objectives) policy? (method + sample size) monitoring? review results are completed happened
Patient Alerts that have: 4.0 Process Report to Group Information Team Monthly Group Quality and Group Quality and Minutes of
Passed the mandatory Manager, Clinical and Safety Group Safety Group meetings/
review date Service Leads action plans
Due to pass mandatory signed off
review date in next 30 EHR Clinical Dashboard
days since last review
(95% of alerts reviewed
before passing mandatory
review date)
Patient Alerts - 4.0 Process Patient Alert Clinical and Information Annually Group Quality and Group Quality and Minutes of
appropriateness and Quality Audit - 5 random Governance and Safety Group Safety Group meetings/
supporting information (95% alerts from each service the Information action plans
alerts are appropriate and for each alert type are Team signed off
95% of alerts have good reviewed
quality supporting
information)
24 hour turnaround 4.0 Process Report - to be included as Information Team Monthly/ Group Quality and Group Quality and Minutes of
(excluding weekends) of the appendix in the Patient Annually Safety Group Safety Group meetings/
centrally managed patient Alert Clinical and Quality action plans
alerts (95% 24 hour alert Audit signed off
turnaround)
Appendix 1
Alerts Types
The below table provides the Alert Type broken down within the four Alert Categories
Appendix 2
Before completing this from please ensure that you have read the Trusts Clinical
Information Systems Patient Alerts Policy which can be found on the intranet.
Your request should be raised on the Information Team helpdesk via the intranet
It will then considered at the next Quality and Safety Steering Group and you may be
asked to attend to discuss details of your request
Questions Response
What alert is required
Why is the alert required
What is the benefit to: - the patient - The
Trust/the Department/the Clinical Teams
Is the Alert a permanent condition? (NB:
generally alerts for temporary conditions
are not approved unless there is sufficient
evidence that the department can
maintain the status of the alert on the
patients record efficiently in line with the
patients care)
What is the expected action of staff upon
seeing the Alert i.e. what does your
department expect staff to do? Where a
non- clinical action is required, it should
be obvious to the viewer of an Alert.
What are the expected number of
patients
Are the alerts to be added retrospectively
or prospectively
Once added to the system and to the
policy, how do you intend to communicate
the existence of the alert and any change
in protocol? i.e. Trust Briefing, memos
etc.
What should the alert description read
Any other supporting information
Who is requesting the alert:
Name:
Role:
Group:
Service:
Appendix 3
STEP 1: Access the IT Services page on the Intranet, available via Online Tools.
Support Issue: Select one of the following options from the drop down menu:
- Alert/Marker Request
- Alert/Marker Removal
Your Message:
Include within the
main space the Alert
Type and Alert
Content and the
OASIS number or
patient identifier for
the patient.
STEP 7: Click S
Policy Details
* For more information on the consultation process, implementation plan, equality impact assessment,
or archiving arrangements, please contact Corporate Governance