Farah Magrabi1, Maureen Baker2, Ipsita Sinha3, Mei-Sing Ong4, Stuart Harrison2, Michael R Kidd5, William B Runciman6, Enrico Coiera4. 1. Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, Australia. Electronic address: farah.magrabi@mq.edu.au. 2. Health and Social Care Information Centre, Leeds, England. 3. Oxford University NHS Trust, England. 4. Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, Australia. 5. Faculty of Medicine, Nursing and Health Sciences, Flinders University, Australia. 6. The School of Psychology, Social Work & Social Policy, University of South Australia, Australia; Australian Patient Safety Foundation, Adelaide, Australia.
Abstract
OBJECTIVE: To analyse patient safety events associated with England's national programme for IT (NPfIT). METHODS: Retrospective analysis of all safety events managed by a dedicated IT safety team between September 2005 and November 2011 was undertaken. Events were reviewed against an existing classification for problems associated with IT. The proportion of reported events per problem type, consequences, source of report, resolution within 24h, time of day and day of week were examined. Sub-group analyses were undertaken for events involving patient harm and those that occurred on a large scale. RESULTS: Of the 850 events analysed, 68% (n=574) described potentially hazardous circumstances, 24% (n=205) had an observable impact on care delivery, 4% (n=36) were a near miss, and 3% (n=22) were associated with patient harm, including three deaths (0·35%). Eleven events did not have a noticeable consequence (1%) and two were complaints (<1%). Amongst the events 1606 separate contributing problems were identified. Of these 92% were predominately associated with technical rather than human factors. Problems involving human factors were four times as likely to result in patient harm than technical problems (25% versus 8%; OR 3·98, 95%CI 1·90-8.34). Large-scale events affecting 10 or more individuals or multiple IT systems accounted for 23% (n=191) of the sample and were significantly more likely to result in a near miss (6% versus 4%) or impact the delivery of care (39% versus 20%; p<0·001). CONCLUSION: 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.
OBJECTIVE: To analyse patient safety events associated with England's national programme for IT (NPfIT). METHODS: Retrospective analysis of all safety events managed by a dedicated IT safety team between September 2005 and November 2011 was undertaken. Events were reviewed against an existing classification for problems associated with IT. The proportion of reported events per problem type, consequences, source of report, resolution within 24h, time of day and day of week were examined. Sub-group analyses were undertaken for events involving patient harm and those that occurred on a large scale. RESULTS: Of the 850 events analysed, 68% (n=574) described potentially hazardous circumstances, 24% (n=205) had an observable impact on care delivery, 4% (n=36) were a near miss, and 3% (n=22) were associated with patient harm, including three deaths (0·35%). Eleven events did not have a noticeable consequence (1%) and two were complaints (<1%). Amongst the events 1606 separate contributing problems were identified. Of these 92% were predominately associated with technical rather than human factors. Problems involving human factors were four times as likely to result in patient harm than technical problems (25% versus 8%; OR 3·98, 95%CI 1·90-8.34). Large-scale events affecting 10 or more individuals or multiple IT systems accounted for 23% (n=191) of the sample and were significantly more likely to result in a near miss (6% versus 4%) or impact the delivery of care (39% versus 20%; p<0·001). CONCLUSION: 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.
Authors: Dean F Sittig; Adam Wright; Enrico Coiera; Farah Magrabi; Raj Ratwani; David W Bates; Hardeep Singh Journal: Health Informatics J Date: 2018-12-11 Impact factor: 2.681
Authors: F Magrabi; E Ammenwerth; H Hyppönen; N de Keizer; P Nykänen; M Rigby; P Scott; J Talmon; A Georgiou Journal: Yearb Med Inform Date: 2016-11-10
Authors: E Borycki; J W Dexheimer; C Hullin Lucay Cossio; Y Gong; S Jensen; J Kaipio; S Kennebeck; E Kirkendall; A W Kushniruk; C Kuziemsky; R Marcilly; R Röhrig; K Saranto; Y Senathirajah; J Weber; H Takeda Journal: Yearb Med Inform Date: 2016-11-10
Authors: Manuel Vélez-Díaz-Pallarés; Ana María Álvarez Díaz; Teresa Gramage Caro; Noelia Vicente Oliveros; Eva Delgado-Silveira; María Muñoz García; Alfonso José Cruz-Jentoft; Teresa Bermejo-Vicedo Journal: Int J Clin Pharm Date: 2017-05-24