The effects and preventability of 2627 patient safety incidents related to health information technology failures: a retrospective analysis of 10 years of incident reporting in England and Wales

Abstract

Background The use of health information technology (IT) is rapidly increasing to support improvements in the delivery of care. Although health IT is delivering huge benefits, new technology can also introduce unique risks. Despite these risks, evidence on the preventability and effects of health IT failures on patients is scarce. In our study we therefore sought to evaluate the preventability and effects of health IT failures by examining patient safety incidents in England and Wales.Methods We designed our study as a retrospective analysis of 10 years of incident reporting in England and Wales. We used text mining with the words "computer", "system", "workstation", and "network" to explore free-text incident descriptors to identify incidents related to health IT failures following a previously described approach. We then applied an n-gram model of searching to identify contiguous sequences of words and provide spatial context. We examined incident details, recorded harm, and preventability. Standard descriptive statistics were applied. Degree of harm was identified according to standardised definitions and preventability was assessed by two independent reviewers. FindingsWe identified 2627 incidents related to health IT failures. 2557 (97%) of 2627 incidents were assessed for harm (70 incidents were excluded). 2106 (82%) of 2557 health IT failures caused no harm to patients, 331 (13%) caused low harm, 102 (4%) caused moderate harm, 14 (1%) caused severe harm, and four (<1%) contributed to the death of a patient. 1964 (75%) of 2627 incidents were deemed to be preventable.Interpretation Health IT is fundamental to the delivery of high-quality care, yet there is a poor understanding of the effects of IT failures on patient safety and whether they can be prevented. Failures are complex and involve interlinked aspects of technology, people, and the environment. Health IT failures are undoubtedly a potential source of substantial harm, but they are likely to be under-reported. Worryingly, three-quarters of IT failures are potentially preventable. There is a need to see health IT as a fundamental tenet of patient safety, develop better methods for capturing the effects of IT failures on patients, and adopt simple measures to reduce their probability and mitigate their risk.

Usability of electronic health record systems in UK EDs

“…Fragmented displays can prevent coherent views of patients' medications, and lead to prescription errors; deaths have been associated with health IT failures, and in Pittsburgh, Pennsylvania, USA a rise in paediatric mortality was coincident with a new system implementation. [27][28][29] Within systems, there is a balance to be struck between the precision of coded data and the value of the precision, while recognising that often precision may be spurious. Data options must be precise enough to enable clinically accurate and safe communication but be easy to navigate for clinicians.…”

Is it time to end the use of imperial measurements?

“…The NHS relies on staff from outside of the UK who predominantly work with metric measurements and expect to continue this, but are often confronted with staff using a hybrid approach, which could cause misunderstandings and errors. Martin et al (2019) found that in a decade of retrospective analysis within the UK, there were 2627 health information technology failures that led to safety events. Perhaps similar research is needed to assess any issues linked with measurements and their communication, especially aspects related to the use of imperial measurements alongside accepted metric units.…”

Using patient safety-event report data to assess health-IT safety: benefits and challenges

“…Previous studies have used these data to understand the general effects of health IT on safety and have focused on specific topics, such as usability, downtime, and interoperability. [2][3][4][5][6][7] In The Lancet Digital Health, Guy Martin and colleagues 8 describe one of the largest analyses of health IT safety failures using a database of more than 13 million patient safety-event reports, and provided further evidence for the association between health IT and patient harm. 2627 events were identified as being related to health IT.…”

“…We discuss these benefits and challenges in the context of understanding health IT safety with a focus on the study by Martin and colleagues. 8 It is important to recognise that identifying health IT-related safety issues, particularly those related to the electronic health record (EHR), can be difficult, given that this technology is now a natural part of the care process and many clinicians might not attribute a safety concern to the EHR or other types of health IT.…”