Resuscitation documentation, messaging apps and a 90-day improvement plan
After a serious incident, a review finds that the cardiac arrest team was called to a patient with a documented 'not for CPR' decision. The decision was written on a paper form, scanned into the electronic record 11 days later, and never entered on the electronic summary that the emergency team sees. The resuscitation officer also finds that on-call doctors use a personal WhatsApp group to share patient identifiers and overnight plans. An audit of 40 'not for CPR' forms shows 14 lacked any documented capacity assessment and 9 had no senior review. The trust asks you for a 90-day improvement plan with measurable outcomes.
1. Analyse the information governance problem and the immediate action required.
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Why the group is a problem. A personal messaging account used for patient-identifiable information is processing personal data outside any controlled system: there is no lawful basis documented, no data protection impact assessment, no retention or deletion rule, no ability to respond to a subject access request, no audit trail of who saw what, and no security if a phone is lost or shared. It also creates a parallel clinical record that may contain decisions that never reach the notes.
Immediate action. Stop using it for anything identifying, today, and tell the staff why rather than simply banning it. Move coordination to an approved secure messaging tool or, if none exists, to phone handover with a written entry. Instruct staff to delete the identifiable content once it has been transferred to the record; do not delete the clinical content itself without capturing what was decided.
Escalate. This is a personal data breach. Notify the data protection officer promptly, support the assessment of risk to the individuals whose information was shared, and record the incident and the remedial actions. Consider whether affected patients need to be told.
2. Design the 90-day plan. What would you do first, and what would you measure?
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Days 0-14 - make the current position safe. Create a single source of truth for resuscitation status that the emergency team actually sees: an electronic flag plus a verbal check at every handover and at the start of every arrest call. Any patient whose status is uncertain is treated as for resuscitation until confirmed. Stop the messaging practice.
Days 15-45 - fix the form and the process. Rebuild the form with mandatory fields: the decision, who made it, capacity assessment, discussion with the patient or best interests process, senior review, and date of review. Make scanning same-day part of the ward round checklist. Train the clinical teams, using their own audit data.
Days 45-90 - embed and verify. Weekly run charts on: percentage of forms with all mandatory fields complete; percentage scanned and flagged on the electronic summary within 24 hours; percentage with documented senior review.
Use small plan-do-study-act cycles with the ward teams rather than one big launch, and re-audit at 90 days with the same sample size and method so the comparison is honest.
3. How would you present the audit findings so that they drive change rather than defensiveness?
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Lead with the system, not the individuals. Open with what the audit was for - making sure the right decision reaches the right people at the right moment - and state the standard before showing the results.
Present the numbers plainly, including the denominator and the method, and be explicit about what the audit cannot tell you: it did not assess whether each decision was clinically right, only whether it was documented and reviewed.
Anticipate the reasonable explanations. Eleven-day scanning is usually a workflow problem, not indifference; missing capacity assessments often reflect uncertainty about how to assess capacity rather than neglect.
Involve the teams in the redesign. Ask the clinicians who complete the forms what would make them usable, and test the new version with them before rolling it out.
Close the loop. Say who owns each action, by when, and when the re-audit will happen, and report back to the same groups who supplied the data. An audit that is never re-audited teaches staff that audit has no consequences.