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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

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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
Authors: Martin, G
Ghafur, S
Cingolani, I
Symons, J
King, D
Arora, S
Darzi, A
Item Type: Journal Article
Abstract: 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.
Issue Date: 3-Jul-2019
Date of Acceptance: 10-May-2019
URI: http://hdl.handle.net/10044/1/73963
DOI: https://dx.doi.org/10.1016/s2589-7500(19)30057-3
ISSN: 2589-7500
Publisher: Elsevier BV
Start Page: e127
End Page: e135
Journal / Book Title: The Lancet Digital Health
Volume: 1
Issue: 3
Copyright Statement: © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/)
Sponsor/Funder: National Institute for Health Research
National Institute of Health Research
Funder's Grant Number: n/a
Publication Status: Published
Online Publication Date: 2019-06-27
Appears in Collections:Department of Surgery and Cancer
Institute of Global Health Innovation