Psychiatric Bulletin (2004) 28: 324-325. doi: 10.1192/pb.28.9.324
© 2004 The Royal College of Psychiatrists
Psychiatric Bulletin (2004) 28: 324-325
© 2004 The Royal College of Psychiatrists
Audit of disposal of clinically confidential information
Craige Dietrich, Senior House Officer in Psychiatry
Central and North West London Mental Health Trust
Zahir Khan, Senior House Officer in Psychiatry
Central and North West London Mental Health Trust
James Warner, Senior Lecturer/Consultant in Old Age Psychiatry
Imperial College London, Department of Psychiatry, Paterson Centre, 20
South Wharf Road, London W2 1PD.
Declaration of interest
None.
Correspondence:
E-mail:
j.warner{at}imperial.ac.uk
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Abstract
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AIMS AND METHOD
We conducted a 3-cycle audit of disposal of clinically sensitive
information in a mental health unit, in order to identify and reduce potential
breaches in patients’ confidentiality. Material from waste bins in
administrative areas of a mental health unit was examined every evening during
each period of the audit.
RESULTS
The first search, conducted over a 3-week period, yielded 11 documents
containing highly-sensitive information about patients. After feedback to
staff and improvement of shredding facilities, no sensitive information was
found during the follow-up 3-week survey, 3 months later. However, a third
survey 2 years later found 24 highly-sensitive items after one week, despite
shredding facilities being maintained.
CLINICAL IMPLICATIONS
Changes in behaviour identified in this audit appear to be due to education
rather than improved facilities. All staff involved in patient care need to
maintain awareness of the need for safe disposal of confidential material.
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Introduction
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Except under exceptional circumstances, clinicians have a duty to keep
patient-related information confidential, especially outside the clinical team
(Dolan, 2004;
National Health Service, 2003). Failure to do so may result in internal disciplinary action or legal
sanctions, as well as endangering doctor-patient relationships if unwitting
disclosure comes to light. We became aware that some written material
concerning patients was being discarded in waste bins. These bins were emptied
daily into the hospital’s general refuse system, creating a possibility
that clinical information could reach unauthorised third parties. In order to
identify the magnitude of this issue, we conducted an audit of unsatisfactory
disposal of clinically sensitive documents relating to patients on a mental
health unit.
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Methods
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We examined the contents of all waste-paper baskets and receptacles in the
administrative areas of one mental health unit, which included seven clinical
teams in general adult and old age services. Doctors’ and
secretaries’ offices, seminar rooms, the photocopy machine room, library
and corridor were searched each evening during the audit cycles. Colleagues
were unaware that searches would take place. The gold standard for this audit
was no pieces of confidential information being discarded.
All documents obtained from waste bins were examined, and those that were
judged to contain clinical information on patients were rated blindly by two
authors (Z.K. and J.W. or C.D. and J.W.). Material was categorised as
‘sensitive’ if it identified a patient and linked him/her to the
mental health unit, but provided no other information. Material was regarded
as ‘very sensitive’ if it identified a patient and contained
details of history, diagnosis, treatment, Mental Health Act 1983 status, drug
or alcohol use or other personal information.
Results of the initial survey were fed back to all relevant members of
staff by a letter outlining the findings and a presentation at a staff
academic meeting. As a result of the first audit cycle, a document shredder
was moved from an office to a communal part of the unit and an additional
confidential bin for safe disposal (by remote shredding) was installed.
Follow-up surveys using the same methods were conducted at 3 months and 24
months after promulgation of the initial survey. The first two search cycles
were 3 weeks long; the third was truncated to one week because of the amount
of data amassed.
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Results
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Results of the three audit cycles are shown in
Table 1. Some documents
contained reference to more than one individual. In each case where multiple
individuals were named, all items were judged to be extremely sensitive. The
first search yielded 14 separate documents, 11 of which were judged to contain
extremely sensitive clinical information. Three items that were recovered only
gave names and dates of birth of patients. One set was torn in half, but was
easily reassembled. No one clinical team or individual was identified as the
source of the confidential material. After the initial audit and promulgation
of the results, the second cycle found no confidential documents. However, a
third cycle completed after a longer interval found a large number of
highly-sensitive documents.
Examples identified during the three audits of ‘highly
sensitive’ information linked to patients’ names included:
- referral forms
- Mental Health Review Tribunal notification
- care programme approach care plans
- several partially completed psychiatric reports
- one complete psychiatric report
- psychiatric out-patient letters addressed to a general practitioner
- one set of ‘handover’ notes for a locum, listing 24 patient
names, their diagnoses, treatment plans, medication and past history
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Discussion
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We were surprised about the large amounts of confidential material
recovered from the first survey. The findings of this survey demonstrated the
need for staff to be cautious with patient-sensitive material to ensure that
confidentiality is not undermined. Consequently, we organised rapid and
comprehensive dissemination of the results and discussed the findings with
local managers, who arranged more accessible and less time-consuming shredding
facilities. We felt reassured by the nil return of the second survey, and
imputed this to be due to the provision of these facilities as much as to the
increased awareness of staff about need to ensure confidentiality. The third
audit had taken place after many of the staff had changed, including the
appointment of two new consultants. The shredding facilities were still in
place. The high return of the third search suggests that education, rather
than facilities provided, is more important in affecting change of behaviour
on this issue.
The documents found were distributed throughout the offices in the search
area. It is worth noting that some bins offered up no documents, while others
provided a daily supply. Particularly bountiful bins were in areas shared by
several people and those found close to fax machines.
During this audit, we had concerns about entering offices without
permission and having access to detailed confidential information. However, we
feel that highlighting the extent of the problem and the need for intervention
exceeded the potential confidentiality breach inherent in this study. Only
clinicians were involved in the audit, and we kept our scrutiny of the
material to a minimum. Once the information had been documented, it was
shredded.
We recommend that in addition to easily-accessible shredders, mental health
units institute regular education on the duty of confidentiality to all
members of staff that have access to confidential patient information.
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References
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DOLAN, B. (2004) Medical records. Disclosing
confidential clinical information. Psychiatric
Bulletin, 28, 53
-56.[Free Full Text]
NATIONAL HEALTH SERVICE (2003) Confidentiality: NHS Code of
Practice. London: Department of Health:
www.dh.gov.uk/assetRoot/04/06/92/54/04069254.pdf
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Abstract
Introduction
