Classifying Health Information Technology patient safety related incidents – an approach used in Wales

Summary

Interest in the field of patient safety incident reporting and analysis with respect to Health Information Technology (HIT) has been growing over recent years as the development, implementation and reliance on HIT systems becomes ever more prevalent. One of the rationales for capturing patient safety incidents is to learn from failures in the delivery of care and must form part of a feedback loop which also includes analysis; investigation and monitoring. With the advent of new technologies and organizational programs of delivery the emphasis is increasingly upon analyzing HIT incidents.

This thematic review had two objectives, to test the applicability of a framework specifically designed to categorize HIT incidents and to review the Welsh incidents as communicated via the national incident reporting system in order to understand their implications for healthcare. The incidents were those reported as IT/ telecommunications failure/ overload. Incidents were searched for within a national reporting system using a standardized search strategy for incidents occurring between 1^st January 2009 and 31^st May 2011. 149 incident reports were identified and classified. The majority (77%) of which were machine related (technical problems) such as access problems; computer system down/too slow; display issues; and software malfunctions. A further 10% (n = 15) of incidents were down to human-computer interaction issues and 13% (n = 19) incidents, mainly telephone related, could not be classified using the framework being tested.

On the basis of this review of incidents, it is recommended that the framework be expanded to include hardware malfunctions and the wrong record retrieved/missing data associated with a machine output error (as opposed to human error).

In terms of the implications for clinical practice, the incidents reviewed highlighted critical issues including the access problems particularly relating to the use of mobile technologies.

Keywords

Medical informatics - Patient Safety - Risk Management - Incident Reporting - Wales

• References

• 1 Sittig D, Classen D. Safe electronic health record use requires a comprehensive monitoring and evaluation framework. JAMA 2010; 303: 450-451.
• 2 Institute of Medicine.. Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC: The National Academies Press; 2012
• 3 Myers R, Jones S, Sittig D. Review of reported clinical information system adverse events in US food and drug administration databases. App Clin Informatics 2011; 2: 63-74.
• 4 Benn J. et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care 2009; 18: 11-21.
• 5 Newton RC. et al. Making existing technology safer in healthcare. Qual Saf Health Care 2010; 19: i15-i24.
• 6 Braithwaite J, Westbrook M, Travaglia J. Attitudes towards the large-scale implementation of an incident reporting system. Int J Qual Health Care 2008; 20: 184-191.
• 7 National Patient Safety Agency.. Seven Steps to Patient Safety. London: NPSA; 2004
• 8 National Audit Office.. A safer place for patients, Learning to improve patient safety. London: The Stationary Office; 2005
• 9 Shojania K. The elephant of patient safety: what you see depends on how you look. The Joint Commission Journal on Quality and Patient Safety 2010; 36: 399-401.
• 10 Magrabi F, Mei-Sing O, Runciman W, Coiera E. An analysis of computer-related patient safety incidents to inform the development of a classification. J Am Med Inform Assoc 2010; 17: 663-670.
• 11 Magrabi F, Mei-Sing O, Runciman W, Coiera E. Using FDA reports to inform a Classification for health information technology safety problems. J Am Med Inform Assoc 2011; 19: 45-53.
• 12 Aronson J. A pragmatic view of thematic analysis. The Qualitative Report 1994; 2.
• 13 Pfeiffer Y, Manser T, Wehner T. Conceptualising barriers to incident reporting: a psychological framework. Qual Saf Health Care 2010; 19: e60.
• 14 Reiman T, Pietikäinen E, Oedewald P. Multilayered approach to patient safety culture. Qual Saf Health Care 2010; 19: e20.
• 15 Mytton O. et al Introducing new technology safely. Qual Saf Health Care 2010; 19: i9-i14.
• 16 Wallace L. et al. Improving patient safety incident reporting systems by focusing upon feedback –lessons from English and Welsh trusts. Health Serv Manage Res 2009; 22: 129-135.