Documentation and Confidentiality in Hospital Departments of Gastrointestinal Surgery. Summary of countrywide supervision in 2005 of communication between health care personnel and between health care personnel and patients in health trusts that provide surgical treatment for patients with acute diseases and cancer in the gastrointestinal tract

Summary of countrywide supervision in 2005 of communication between health care personnel and between health care personnel and patients in health trusts that provide surgical treatment for patients with acute diseases and cancer in the gastrointestinal tract

In 2005 the Norwegian Board of Health in the counties carried out supervision in 23 health trusts that provide surgical treatment for patients with acute diseases and cancer in the gastrointestinal tract. The theme for supervision was communication between different health care personnel, and between health care personnel and patients.

In nearly two out of three of the departments of gastrointestinal surgery, serious deficiencies were found in recording of patient records by the surgeons. Because of lack of knowledge about confidentiality, organization of the availability of patient records was not properly controlled in many places. In most of the departments of gastrointestinal surgery, the system of allocating patients a doctor with special responsibility for them did not function as intended. In more than one third of the departments of gastrointestinal surgery, patient consultations took place with uninvolved people present, because of limitations in the physical surroundings and because of high pressure of work. The departures from the regulations that were detected were followed up with various local and central measures.

The results of supervision indicate that health services are run with a level of risk that is too high. The awareness of safety that has gained a foothold in other sectors, has not gained sufficient foothold in health services. Even though there is a degree of variation between the health trusts, very often, the services are organized based on the assumption that people working in the system do not make mistakes. Such systems are inherently very unsafe, and safety measures must be initiated.