Trusts should adhere to patient safety standards when implementing new IT systems, a patient safety expert has argued.
Maureen Baker, clinical director of patient safety at the Health and Social Care Information Centre, told last week's UKRC that although the last 20 years had seen an increasing awareness of the importance of patient safety, there was still much to be done.
In the US, for example, an estimated 98,000 people a year die from medical errors occurring in hospital.
“We need to start thinking more critically about when things go wrong. We need to get better at stopping things going wrong in the first place,” she said.
Although human error was inevitable, well-designed systems and processes could minimise the capacity for human error, Baker added.
She also urged the NHS to learn from other industries such as aviation, which had extensive safety management systems in place.
While the adoption of IT systems in healthcare had removed some major causes of error (such as illegible handwritten prescriptions), it had introduced others, Baker told delegates to the congress in Liverpool.
A GP choosing a prescription medicine from a dropdown menu, for example, could accidentally choose a medicine with a similar-sounding name.
Baker said that since systematic recording of safety issues related to IT had begun in 2005, 1,200 incidents had been logged.
Many of these related to patient identification – for example, notes about one patient being assigned to another patient.
Data mapping was a major source of error, because up-to-date information such as patient addresses could be overwritten by older and incorrect information. “Data quality is a patient safety issue,” she said.
The largest group of incidents on the database related to picture archiving and communications systems; the particular concern of the imaging stream at the event.
This does not necessarily mean that there are more problems with PACS, Baker said, but may relate to greater conscientiousness among professionals using PACS.
“Clinicians have been very aware of the importance of logging incidents. This is a culture that has developed in this community.”
John Fox, a quality and safety analyst at the HSCIC, said that the importance of standards was increasingly recognised in the NHS.
For example, Robert Francis QC's second report into the scandal at Mid Staffordshire NHS Foundation Trust had emphasised the need for standards in patient care.
In 2009, two NHS standards were created to address patient safety in IT systems: DSCN 14/2009, which is aimed at manufacturers of health software, and DSCN 18/2009, which is aimed at those deploying and using health software.
They cover topics such as hazard identification, clinical risk analysis, clinical risk evaluation and clinical risk control.
“The specifications explain what you have to achieve, but the organisations decide how to do it,” Fox said; urging delegates to support the standards and to make sure they were used in IT implementations.
Read more about the imaging informatics stream at UKRC in the Insight feature on EHI Imaging Informatics: Reporting the future
© 2013 EHealth Media.
Open Consultationjbfox 55 weeks ago
Users of these NHS standards are invited to participate in an open consultation exercise being run to obtain feedback on the recent revisions. The consultations can be accessed through the following links:
Access to the consulations will be available until Monday 21st October 2013.
Look to other industriesadjhar 62 weeks ago
Having read the comments I could only say look to how other industries regulate safety. The NHS should not be any different and our patients deserve the same protection. There are standards, mandated ones, lets use them to regulate our industry. If you fly in a plane, work on an oil rig, etc. etc. Come on, even tooth brushes are CE marked!
I have personally seen the effort and staff number drop within safety teams in suppliers when they should be boosting numbers! (Ref MHRA ...) This against the backdrop of borderline MDD software being offered to Trusts today.
With respect to Maureen Baker - give your boys guns and badges!
I yjionk that Trusts take IG for more seriously than this conversation says..It is I, LeClerc 62 weeks ago
Most Trusts I know take Info Gov very seriously, not just because of the Tool Kit but because it protects the Trust, the patients and staff too.
IG and safety are 2 vastly different subjectsPSMS 62 weeks ago
The IG toolkit is treated with due regard I agree but that's not what this thread is about - the thread is following Maureen's safety standards for trusts speech. IG toolkit is off topic - this thread relates to the ISB standards for safe implementation of ehealth systems by health organisations - and the lack of resource and compliance monitoring for the standard wrt trust compliance.
Play nicePSMS 62 weeks ago
This thread is about a safety standard with no regulation, the IG toolkit has a completely different purpose albeit it forms part of a control framework which is essential for safe operation. I didn't make personal remarks, I merely said you were off topic. Lets leave it at that?
Oh dear, and you don't think IG is relevent to the topic!It is I, LeClerc 62 weeks ago
Well I am sorry that you don't understand the link between Info Gov and safe implementation (and management) of -health systems by health organisations. Or the tools IT depts. use to monitor IG, security and compliance monitoring. Perhaps things happen differently in your place. But as I am clearly "off thread", I won't comment again.
Work has been done - now needs to be implementedAndyGetReal 62 weeks ago
CFH and Microsoft ran a joint vendor neutral, platform agnostic research program called the Common User Interface to address the precise issue of reducing the risk of patient safety errors using IT systems. The program was driven by patient safety risk assessments, fully involved clinicians, informatics, nurses in the risk assessments to determine potential hazards, produce clinically review UI design guidance for clinical systems, and undertook additional risk assessments to ensure that additional risks weren't introduced in the process. There's a wealth of free information and guidance on a variety of topic (patient identificiation, medication line/lists/administration, clnical noting and terminology to name a few) available to NHS internally ayt http://www.cui.nhs.uk/Pages/NHSCommonUserInterface.aspx or to anyone free without registration at http://www.mscui.net . Some of this design guidance has been through the ISB process. Examples of such are http://www.isb.nhs.uk/documents/isb-1505/dscn-09-2010/index_html . Others can be found at http://www.isb.nhs.uk/use/baselines/cui . I hope Maureen Baker ensures these are used and implemented before trying to reinvent the wheel.
FrustratedPSMS 62 weeks ago
Sorry this is what frustrates me - once again the solution is pitched as "supplier-does"...CUI. I'm working currently with a couple of different progressive responsible suppliers who have patient banner redesigns and major CUI adoptions. They "dig it". On the other hand - what is in place to mandate this work? Nil. Who polices this excellent CUI compliance? Who makes sure systems are implemented safely once the supplier has gone? No one..... on and on. This is a dual tier system. NHS - health thy self.
Where does the front line report patient safety issues?Mary Hawking 62 weeks ago
When we had the NPSA, there was a place where patient safety issues could be reported: when NPSA was abolished (in 2012) this function was transfered to NHS CB (now England).
I cannot find any place to report patient safety issues: could EHI help?
IT - and IT standards *are* important: so is having a reporting/whistle-blowing portal.
Incident reportingKeepItSimple 62 weeks ago
The reporting pages on the NPSA site are still available
http://www.nrls.npsa.nhs.uk/report-a-patient-safety-incident/ In Perhaps
InMay NHSE said it wanted to improve reporting but not how http://www.england.nhs.uk/2013/05/21/reporting-culture/
Perhapsthe NPSA system is still the route to use?
Use NPSA stillMary Hawking 62 weeks ago
Thanks, KeepItSimple: NPSA is still the way to go - even though not obvious!
Still no low level, systemic fault reporting where no patient harmed e.g. abysmal quality EDLs (Electronic Discharge Letters) and A&E reports: are these routinely discarded?
No IT safety regulator for TrustsPSMS 62 weeks ago
Maureen has been an ardent supporter of these standards for years - unfortunately whilst Trusts are keen to flog suppliers to implement the standards - as she quite correctly points out here - the striking absence of Trust IT-safety resource is shocking. What Maureen fails to mention as well is the lack of Regulatory remit for IT-safety. Would the ehealth-IT-safety-regulator please stand up - coz it isn't the MHRA, they washed their hands of it in 2010 (see their website)
What about the IG Toolkit?It is I, LeClerc 62 weeks ago
Not sure I agree with the statement "lack of Regulatory remit for IT-safety" or "the striking absence of Trust IT-safety resource", unless it is reference to funding and resourcing. Have you ever battled year after year with the IGTK, I have to wonder?
Understand your stancePSMS 62 weeks ago
But who is the regulator for e-health safety? Who makes sure these standards are complied with in the Trusts? The Trusts demand safe systems from suppliers (and compliance), but who monitors Trust compliance? The IG toolkit is not designed to do this. A standard is only effective if its policed. This one isn't.
Isn't IGT self-reporting?Mary Hawking 62 weeks ago
As a GP, I have had to struggle with the IGT - and "battling" is a very good term!
However, it is again self-assessment - and as such only useful if the answers (once you've worked out how the question/requirements apply in your own organisation) are accurate and you are in a position to know the real situation.
Haven't we seen the same problem in self assessment for CQC?
Revision to the standardsjbfox 62 weeks ago
The latest versions of the NHS standards identified in this article can be found at:
ISB 0129 (previously DSCN 14/2009) - http://www.isb.nhs.uk/documents/isb-0129/amd-39-2012/index_html
ISB 0160 (previously DSCN 18/2009) - http://www.isb.nhs.uk/documents/isb-0160/amd-38-2012/index_html