The HSSIB completed a thematic review of 50 reports to identify specific patient safety issues and learning related to EPR systems.

The review highlights that EPR systems can improve patient care and support safety, but ‘still contribute to patient care being missed, delayed or recorded incorrectly'. This is despite national recommendations and actions intended to reduce risks. 

 

Common issues include poor usability and interoperability between EPR systems and other software, outdated hardware and infrastructure affecting system performance, and limited resources to support the safe ongoing use of EPR systems.

In a specific case referenced in the report, a four-year-old girl received five incorrect doses of blood-thinning medication, as the prescription was wrongly entered on the electronic prescribing and medicines administration (ePMA) system. The system did not identify the error and this incident contributed to bleeding around her brain.

The report highlights the importance of:

• choosing an EPR system capable of meeting the needs of an organisation
• implementing an EPR system that meets the needs of users
• seeking feedback and ongoing EPR system optimisation.

HSSIB observes that national bodies responsible for providing digital advice and guidance to NHS organisations can improve patient safety by clarifying consistent definitions for design-related IT terms, such as usability and functionality, and sharing guidance on how to apply design principles to electronic patient record system configuration and optimisation.

In addition, HSSIB has identified learning to help consider and mitigate risks around procuring, implementing and optimising EPR systems.

Nick Woodier, senior safety investigator, said: ‘Electronic patient record systems are a central part of modern healthcare and will only become more important as national digital ambitions continue to grow. This report is not a criticism of EPRs themselves; when implemented well, they can bring benefits for patient safety. However, the analysis of our past investigations shows that systems which are poorly implemented, difficult to use, or do not meet the needs of staff and organisations can introduce avoidable patient safety risks, which can contribute to serious harm.

 

‘We note in the report that these issues persist despite national recommendations and concerted efforts to reduce the risks. Ultimately, this review is clear that effective, needs-led implementation is essential to ensure EPRs have a positive impact on safety – this will help close the gap between digital ambitions and the realities of frontline care.'

The full report is available here.