Clinical safety of England's national programme for IT: A retrospective analysis of all reported safety events 2005 to 2011

Abstract

Events associated with NPfIT reinforce that the use of IT does create hazardous circumstances and can lead to patient harm or death. Large-scale patient safety events have the potential to affect many patients and clinicians, and this suggests that addressing them should be a priority for all major IT implementations.

Identifying patient safety problems associated with information technology in general practice: an analysis of incident reports

“…While the broad categories of problems we identified are similar to those previously reported in hospitals,19 20 23 we found that routine updates to software can be particularly problematic in general practice. Issues with software updates generated clinical errors that are unique to IT and can affect many patients at once.…”

“…Incidents were categorised using an existing classification for safety problems associated with health IT 23. Problems were first divided into those primarily involving human factors or technical problems, and then assigned to one or more subclasses.…”

“…Consequences were examined using a standard approach and are as follows:19 20 23 Potential or actual harm to a patient : An incident that reached the patient,21 for example, a patient had a severe allergic reaction to prescribed medication even though allergy was entered in the patient's electronic medical record. An arrested or interrupted sequence or a near miss : An incident that was detected before reaching the patient,21 for example, a prescription in a wrong name noticed and corrected while printing. An incident with a noticeable consequence but no patient harm : Problems that affected the delivery of care but no harm to a patient, for example, time wasted waiting for a printer to function correctly. An incident with no noticeable consequence : Problems that did not directly affect the delivery of care, for example, an electronic backup copy of patient records was corrupted, but this was detected and the copy was not needed. A hazardous event or circumstance : Problems that could potentially lead to an adverse event or a near miss, for example, a prescribing package fails to display a patient's allergy status. A complaint : An expression of user dissatisfaction, for example, a user found that training to use new software was inadequate.…”

An analysis of electronic health record–related patient safety incidents

“…According to a recent study, problems involving human factors were four times more likely to result in harm to patients than technical problems, further stressing the importance of sociotechnical aspects. 18 Moreover, research confirms the importance of a sociotechnical perspective in system design. 45 Incident reporting systems provide a mechanism for identifying safety risks.…”

Improving Evaluation to Address the Unintended Consequences of Health Information Technology

“…Unintended effects not only disrupt the delivery of care but also pose risks to patient safety [10,11]. The adverse outcomes against design intention may be due to context factors such as different health settings, different clinical domains, technical configuration context, or users not adequately prepared [12].…”