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
Summary: 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 o...
| Main Authors: | , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Elsevier
2019-07-01
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| Series: | The Lancet: Digital Health |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S2589750019300573 |
| _version_ | 1819265129040052224 |
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| author | Guy Martin, PhD Saira Ghafur, MSc Isabella Cingolani, PhD Joshua Symons Dominic King, PhD Sonal Arora, PhD Ara Darzi, ProfPhD |
| author_facet | Guy Martin, PhD Saira Ghafur, MSc Isabella Cingolani, PhD Joshua Symons Dominic King, PhD Sonal Arora, PhD Ara Darzi, ProfPhD |
| author_sort | Guy Martin, PhD |
| collection | DOAJ |
| description | Summary: 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. Findings: We 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. Funding: The National Institutes of Health Research Imperial Patient Safety Translational Research Centre at Imperial College London. |
| first_indexed | 2024-12-23T20:40:28Z |
| format | Article |
| id | doaj.art-b69cd1a1031e49428623fb58cf7583ed |
| institution | Directory Open Access Journal |
| issn | 2589-7500 |
| language | English |
| last_indexed | 2024-12-23T20:40:28Z |
| publishDate | 2019-07-01 |
| publisher | Elsevier |
| record_format | Article |
| series | The Lancet: Digital Health |
| spelling | doaj.art-b69cd1a1031e49428623fb58cf7583ed2022-12-21T17:31:56ZengElsevierThe Lancet: Digital Health2589-75002019-07-0113e127e135The 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 WalesGuy Martin, PhD0Saira Ghafur, MSc1Isabella Cingolani, PhD2Joshua Symons3Dominic King, PhD4Sonal Arora, PhD5Ara Darzi, ProfPhD6National Institutes of Health Research Patient Safety Translational Research Centre, St Mary's Hospital, Imperial College London, London, UK; Correspondence to: Dr Guy Martin, National Institutes of Health Research Patient Safety Translational Research Centre, St Mary's Hospital, Imperial College London, London W21NY, UKCentre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UKBig Data and Analytical Unit, Institute of Global Health Innovation, Imperial College London, London, UKBig Data and Analytical Unit, Institute of Global Health Innovation, Imperial College London, London, UKNational Institutes of Health Research Patient Safety Translational Research Centre, St Mary's Hospital, Imperial College London, London, UK; DeepMind Health, London, UKNational Institutes of Health Research Patient Safety Translational Research Centre, St Mary's Hospital, Imperial College London, London, UKNational Institutes of Health Research Patient Safety Translational Research Centre, St Mary's Hospital, Imperial College London, London, UKSummary: 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. Findings: We 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. Funding: The National Institutes of Health Research Imperial Patient Safety Translational Research Centre at Imperial College London.http://www.sciencedirect.com/science/article/pii/S2589750019300573 |
| spellingShingle | Guy Martin, PhD Saira Ghafur, MSc Isabella Cingolani, PhD Joshua Symons Dominic King, PhD Sonal Arora, PhD Ara Darzi, ProfPhD 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 The Lancet: Digital Health |
| title | 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 |
| title_full | 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 |
| title_fullStr | 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 |
| title_full_unstemmed | 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 |
| title_short | 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 |
| title_sort | 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 |
| url | http://www.sciencedirect.com/science/article/pii/S2589750019300573 |
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