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Electronic Patient Records promise safer, faster care – but when systems fail, poorly configured software and fragmented governance can put patients at serious risk. Simon Bowgen from Maulin Group’s investigations team, examines what recent NHS incidents reveal about EPR safety, and why fixing it requires more than blaming the individual.
Electronic Patient Records has fundamentally created opportunities to improve patient safety and reduce clinical risk. They provide instant access to up-to-date records, reduced test result wait times, clearer communication between healthcare departments and whole access to a patient’s medical history.
However, centralisation of patient records consequently encompasses multiple clinicians, software and processing. Digitising complex care plans requires interoperable systems. If a system fails, it risks patient harm, even when no deliberate wrongdoing has occurred.
This article will examine the anatomy of EPR workflow disruption alongside human-centred mitigation. System design, usability, governance and interoperability will be assessed to demonstrate EPR safety cannot be singularly focused as an individual’s responsibility, but rather it is dependent on cooperation between the system users, system function and the organisation in which it operates.
EPR workflow disruption
EPRs which enable departmental customisation risks workflow disruption, without established clinical governance and policy implementation. Health Services Safety Investigations Body (HSSIB) reported a paediatric ward incident in an unnamed Trust, where an unconfigured electronic prescribing system (ePMA) quick list still included adult dosages, with no guardrails in place to catch this unusual dosage. The patient subsequently received over ten-times the recommended dosage on multiple occasions, causing intercranial bleeding. The clinical leadership team failed to appropriately audit the system prior implementation into paediatric care. The HSSIB investigation further discovered that the clinical staff had concerns about the implementation of the ePMA system to paediatrics before integration, with some clinicians failing to recall any training on this system.
The failure of clinical governance allowed a flawed tool system for frontline use. To better understand EPR workflow risk, we must look beyond clinical management and towards the usability of software interface. Clinicians work in a high-demanding, time-pressured environment. Convoluted systems contradict the environment they are required to operate in, as seen in the case of Darnell Smith. Royal Hallamshire Hospital staff were not aware that Darnell’s vitals required monitoring hourly due to the digital system not making his care plan easily visible. Darnell sadly passed two weeks later. This has not been an isolated incident. In 2017, an investigation at Nottingham University Hospitals revealed more than 400,000 digital letters to patients and GPs had failed to send as they required signing-off and were placed in an unknown folder. A clear association can be seen between cognitive overload and alert fatigue with inefficient EPR use and patient harm.
Poor interface design makes patient information difficult to locate. Poor interoperability makes information and clinical responsibility difficult to transfer within a hospital. Patient data needs to be able to be interpreted correctly by the varying systems. Failure to act upon these can risk severe delays in patient referrals, medicine requests or tests. This was demonstrated at the launch of Cambridge University Hospitals EPR, where the system became unstable, resulting in pathology test results not correlating to the correct patient. This required manual checking and for blood tests to be re-ordered, dropping A&E performance by 20% and losing staff confidence. Inaccurate and delayed patient data from poor system interoperability greatly increased the risk of patient harm.
Human-centred solutions
We have assessed the impact of poor clinical management on patient risk. However, in a system with a clear chain of command and responsibilities outlined, governance is fundamental in EPR safety. When NHS England issued the National Patient Safety Alert for the Euroking maternity system due to data overwriting, rapid clinical oversight and escalation took place before patient harm could occur. Trusts audited their Euroking systems to identify where data corruption could occur, and many Trusts replaced the system to ensure long-term patient safety. Resultantly, there were no records of direct patient harm from this incident.
When Colchester General Hospital’s electronic communication system for patient handovers was not sufficient, a development team which grouped staff from varying hospital departments formed Watchpoint. This supported the identification and escalation of clinical tasks and was continuously developed from clinician feedback. Following its introduction in 2015, a study into the impact of Watchpoint showed an 87% reduction in cardiac arrests from failure to escalate, and wait times reduced from 158 to 102 minutes. The solution was developed by people experiencing the workflow problem in varying departments, and clinical users helped shape the intervention.
The University Hospitals of Leicester faced an interoperability EPR workflow risk when a significant prescribing error rate in discharge medication was identified. This was caused by manual transcription of medication between their two systems, ePMA and Integrated Care Environment (ICE). To mitigate this, an interface between the two systems was developed which included the safeguard that medication imported from the prescribing system could not be amended on the discharge letter. Changes had to be made on the former to transfer across to the discharge letter. Making the two systems compatible eliminated transcription errors, reduced prescribing errors and fastened the discharge medication process for staff.
How we help support safer digital healthcare
At Maulin Group, we provide clinical and investigative insight to support healthcare systems, recognise and alleviate EPR patient risks. Our approach strongly recognises that electronic patient safety is a shared responsibility between system users, healthcare organisations as well as IT departments. Despite the transition to digital records, we have identified longstanding issues remain. Inconsistencies within patient data and the continued absence of key clinical information continue to risk patient safety. At Maulin Group, our understanding of clinical governance, system usability and interoperability enables us to assist organisations in investigating how electronic workflows can be made safer.
