A male patient's hand rests on a nurse call button in a hospital bed

Identification of critical patient information at the bedside – Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)


The national investigation

We have launched an investigation that explores the challenges NHS hospital staff face when trying to access key information about their patients, at the patient bedside.

This key information includes:

  • a patient’s identity
  • whether attempts at resuscitation should be undertaken in the event of a cardiac arrest

Cardiopulmonary resuscitation (CPR) is a treatment that can be given when a patient’s heart stops beating or they stop breathing. DNACPR stands for ‘do not attempt cardiopulmonary resuscitation’ which means that if a patient’s heart or breathing stops, the healthcare team will not try to resuscitate them. A DNACPR decision is made by the patient and/or their doctor or healthcare team. It is recorded on a specific form.

The aim of our investigation is to support staff to be able to quickly access the correct information in relation to a patient’s identity and DNACPR status, in time-pressured situations.

Reference event

The reference event involved Patient A who was found by staff having a suspected cardiac arrest in bed on a hospital ward. The staff who found Patient A asked for help from ward staff who attended the patient. At this point Patient A was identified at the bedside as Patient B, who was in the next bed.

Patient B had a DNACPR order in place that meant they would not be resuscitated in the event of a cardiac arrest. This meant that, because Patient A had been identified as Patient B, Patient A did not have resuscitation commenced. Some minutes later Patient A was correctly identified, and resuscitation began.

The events occurred on a hospital ward during a peak of the coronavirus (COVID-19) pandemic. The ward had recently been repurposed from a day-surgery environment to a healthcare of the older person ward. Staff had been redeployed to the ward from across the hospital in support.

Investigation summary

This national investigation explores:

  • the factors that impact on the ability of staff to access critical patient information at the bedside, such as DNACPR status
  • how repurposing of ward environments and redeployment of staff at times of operational pressures may impact on clinical decision making