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监管机构和批评人士对NHS医疗记录的可靠性提出担忧Watchdog and critics raise concerns over reliability of NHS medical records

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接受脑外科医生萨姆·埃尔贾梅尔手术的患者将在正在进行的针对这名名誉扫地医生的公开调查中提出病历不准确或缺失的问题。Patients operated on by brain surgeon Sam Eljamel will raise the issue of inaccurate or missing medical records during the ongoing public inquiry into the disgraced medic

有人对苏格兰使用的英国国家医疗服务体系(NHS)病历系统的可靠性提出了质疑。

Concerns have been raised about the reliability of the NHS medical records systems used in Scotland.

公共服务监管机构已对这些系统的准确性提出质疑,批评者则指出,在安全调查及法庭诉讼中,这些系统的可靠性同样存疑。

Their accuracy has been questioned by the public services watchdog and critics warned there were doubts about their reliability in safety investigations and court cases.

曾接受声名狼藉的脑外科医生萨姆·埃尔贾梅尔治疗的患者们抱怨称,自己的病历存在“大量缺失内容”,且常常无法反映实际的诊疗情况。

Victims of disgraced brain surgeon Sam Eljamel have complained of "significant gaps" in their records and said they often do not reflect the reality of their care.

苏格兰政府表示,他们高度重视这些担忧,目前正在与各卫生委员会商讨提升病历可靠性的具体措施。

The Scottish government said it took the concerns raised seriously and was engaging with health boards over ways to improve the reliability of patient records.

苏格兰存有数百万份病历,其中记录了患者的健康、诊疗及治疗相关信息。一旦出现医疗事故,这些病历便会被用作调查及法律诉讼的依据。

There are millions of patient records in Scotland, which contain information about your health, care and treatment. When things go wrong they are relied upon for investigations and legal challenges.

然而,目前并无统一的NHS中央病历系统,近年来关于病历准确性的问题也屡被提及。

However, there is no central NHS system where these records are kept and a number of concerns about their accuracy have been raised in recent years.

正在进行的苏格兰医院调查针对格拉斯哥伊丽莎白女王大学医院的患者安全问题展开,调查中也出现了关于病历缺失及信息记录方式不当的质疑。

The long-running Scottish Hospitals Inquiry's probe into patient safety issues at Glasgow's Queen Elizabeth University Hospital campus has heard concerns about missing medical records and about how information was recorded.

最近启动的关于埃尔贾梅尔在邓迪九井医院诊疗行为的公开调查,也将重点探讨病历准确性问题。

The issue of accurate medical records will also feature heavily in the recently started public inquiry into the actions of Eljamel at Dundee's Ninewells Hospital.

1995年曾接受埃尔贾梅尔手术的艾伦·奥吉尔维是推动此次调查成立的“患者行动小组”的发言人。

Alan Ogilvie, who was operated on by Eljamel in 1995, is spokesman for the Patients Action Group which campaigned for the inquiry.

艾伦·奥格尔维表示,许多接受埃尔贾梅尔手术的患者对其病历的准确性存在重大担忧。Alan Ogilvie said many patients operated on by Eljamel have major concerns about the accuracy of their medical records

奥吉尔维称,许多受影响的患者发现,官方病历“往往与他们的实际经历不符”。

Ogilvie said many of those affected had found their official medical records "often don't match their lived reality".

他补充道:“病历中出现了大量并发症相关的空白内容,有些描述似乎是为了维护医生的声誉而刻意修改,并未如实反映患者的病史。

He added: "We see significant gaps where complications occurred, and narratives that seem massaged to suit the clinician's reputation rather than the patient's history.

当电脑里的‘官方记录’与我们手写的病历及记忆内容相悖时,我们不禁要问:这个系统存在的意义是记录事实,还是保护医疗机构的利益呢?”

"When the 'official' computer record says one thing, but our own letters and memories prove another, you have to ask: Is the system there to record the truth, or to protect the institution?

“如果我们连过去的医疗记录都无法信任,又怎能相信这些记录能为未来提供有价值的借鉴呢?”苏格兰公共服务监察署(SPSO)屡次指出医疗记录准确性方面的问题。

"If we cannot trust the records from the past, how can we trust the lessons they claim to be learning for the future?" The Scottish Public Services Ombudsman (SPSO) has often raised the issue of accurate medical records.

上个月,爱丁堡皇家医院的一名患者因血液感染去世,苏格兰公共服务监察署批评苏格兰国家医疗服务体系洛锡安地区分部未能对该事件开展重大不良事件调查。

Last month, NHS Lothian was criticised by the watchdog for not carrying out a Significant Adverse Event Review into the death of a patient from a blood infection at the Royal Infirmary of Edinburgh.

监察署发现该患者的护理记录存在诸多令人担忧的疏漏与不完整之处:临床记录中四次提及主治医生要求提供微生物检测报告,但患者的病历中却没有任何相关报告的痕迹。

The SPSO found "concerning" gaps or incomplete nursing records for the patient These included four occasions where it said in the clinical notes that the doctor in charge had asked for a microbiology report - but there was no evidence of such a report in the patient's clinical records.

目前,针对两个月大的迈克尔·威尔逊在阿伯丁皇家儿童医院去世事件的致命事故调查仍在进行中,调查的重点正是各医疗服务机构之间患者医疗信息的共享机制。

The sharing of information from patient records between NHS boards is the focus of an ongoing fatal accident inquiry (FAI) into the death of two-month-old Michael Wilson at the Royal Aberdeen Children's Hospital.

调查中,一名医生作证称:若能从迈克尔的病历中得知其患有遗传性心脏病,他绝不会建议为这名患儿实施手术。两年前,这种心脏病也曾被怀疑是导致迈克尔哥哥在格拉斯哥去世的原因。

The inquiry has heard from a doctor who said he would have advised against operating on Michael if he had known, from the child's medical records, about an inherited heart condition. It had been the suspected cause of death of Michael's older brother in Glasgow two years previously.

据《新闻与期刊报》报道,在早前的一次听证会上,地方法官克里斯汀·麦克克罗斯南指出:“当前的医疗记录管理状况已近乎需要开展公开调查的程度——这可是关乎整个国家医疗体系根基的问题。各医疗服务机构各自独立运营,其使用的计算机系统似乎也无法实现互通。”

At an earlier hearing the Press and Journal reported that Sheriff Christine McCrossan said: "It's almost verging into a public inquiry situation - something as fundamental as the medical records situation in the country. "These boards are inde­pend­ent and they set up com­puter sys­tems that don't seem to talk to each other."

工党议员丹尼尔·约翰逊表示,一些重要问题需要得到解答。Labour MSP Daniel Johnson said important questions need to be answered

工党议员丹尼尔·约翰逊表示,医疗记录对医务人员而言是极其宝贵的资料。“但既然其他公共机构乃至皇家检察署都开始依赖这些记录,我们就必须确保它们的绝对可靠性。”他补充道。

Labour MSP Daniel Johnson said medical records were an invaluable resource for medics. "But at the point they are being relied upon by other public agencies, including the Crown Office, we need absolute clarity about their reliability," he added.

“关于皇家检察署、中央法律办公室及其他由公共资金资助的机构究竟如何评估患者病历的可靠性,以及支撑这些病历使用的相关操作规范,还有许多重要问题亟待解答。”苏格兰政府发言人说道:“我们深知,准确、完整且易于获取的患者病历对于保障医疗安全、确保治疗连贯性以及有效调查不良事件至关重要。”

"Important questions need to be answered about how the Crown Office, the Central Legal Office and other publicly funded bodies assess the reliability of patient medical records and the user protocols which support their use." A Scottish government spokesperson said: "We recognise that accurate, complete and accessible patient records are essential to safe care, continuity of treatment and effective investigation of adverse events.

“各NHS管理委员会负责管理其所辖的电子病历系统,并须确保临床信息的准确性、安全性、可获取性以及管理规范性。”该发言人还指出,为提升病历系统的可靠性,当局已采取一系列保障措施,包括制定全国性标准及实施数据质量控制。

"NHS boards are responsible for the electronic patient record systems they operate and for ensuring that clinical information is accurate, secure, accessible and appropriately governed." The added a range of assurance mechanisms to support the reliability of patient record systems were used including national standards and data quality controls.

“我们高度重视近期调查所反映出的各类问题,并将继续与各管理委员会保持沟通,认真研究相关调查结果及改进建议,以期进一步提升患者病历的可靠性,从而保障医疗服务的安全与高效。”

The spokesperson said: "We take the concerns raised from recent inquiries seriously and continue to engage with boards to consider findings and any recommendations for improving the reliability of patient records to support safe and effective care."