NHS England recently issued a national patient safety alert to all trusts providing maternity services after faults were discovered in IT software that could pose “potential serious risks to patient safety”. In this short blog, Clive Flashman, Patient Safety Learning’s Chief Digital Officer, calls for a closer look at the reasons into this and what we can learn from it.
Electronic patient records (EPRs) are a way of managing clinical information with the intention of making this information more easily accessible for use by healthcare professionals. In A plan for digital health and social care published in June 2022, the Department of Health and Social Care set a target that all NHS Trusts should have an EPR system by March 2025.[1] In November last year, NHS England announced it was on course to meet this target, stating that 90% of NHS trusts have now introduced these new systems.[2]
Although EPRs have the potential to significantly improve patient care and information handling, there are also a number of patient safety risks associated with their implementation and use. In a recent blog reviewing the recurring themes identified through their safety investigations, the Health Services Safety Investigations Body (HSSIB) identified a number of these:[3]
- Interoperability – problems stemming from EPRs being unable to exchange or make use of information from other IT systems used by trusts.
- Usability testing of software – EPR systems being introduced without appropriate testing of how easy or difficult healthcare professionals tasked with using these find them to operate.
- Standards and standardisation – EPR systems in use not incorporating human factors engineering principles in their design to ensure they are the best they can be.
The themes listed above have been highlighted in recent media coverage, including recently a number of patient safety incidents and a patient death related to the introduction of a new EPR at the Royal Surrey Foundation Trust and St Peter’s Hospital Foundation Trust.[4]
Patient Safety Alert
Euroking is an EPR provided by Magentus Software. According to an NHS England National Patient Safety Alert issued on the 7 December 2023, the Euroking EPR has been found to process information incorrectly — overwriting the existing record with new information and incorrect storage and display of safeguarding information, which could lead to “incorrect management of the pregnancy and subsequent harm”.[5]
The Euroking EPR is used in the maternity departments of at least 15 NHS trusts according to information held by HSJ.[6]
NHS England has said there is “currently no evidence of actual harm being reported as a result of these issues" and the Trusts involved have 6 months to deal with it.
The alert tells Trusts to review their data within the system and consider if Euroking meets their maternity services requirements and is safe, looking at replacement systems if deemed necessary. However, what is unclear from this Alert is whether NHS England had already spoken to the vendor and asked for a fix to be created and pushed out as soon as possible. Commenting in response to the Alert, Euroking have said that they were working with NHS England on issues concerning the data fields in the system and have provided their customers with ”support and information”.
More robust response needed
At Patient Safety Learning we don’t believe this is an adequate response to the issues raised in this Patient Safety Alert.
A more robust response could have involved NHS England having been clear about the changes that were needed from a patient safety perspective and, subsequently, having worked with Euroking to make these changes and then push out this fix to all existing users as soon as possible. If that had been done, this Patient Safety Alert could have looked quite different, focused on the need to update the software first by a certain date, then check each data field and add back in any overwritten data if still available. This would also mean that the need to potentially consider moving to a new system, a potentially expensive and disruptive change, could then have been a lower priority.
Although this issue and subsequent Alert relates to a specific vendor and system, we also believe it would be useful for all trusts to check that the same issue is not affecting similar systems (all EPRs, not just their Maternity one) from other vendors. It would have been helpful for NHS England to have annexed their alert with a testing process to support trusts in this.
References
[1] Department of Health and Social Care. A plan for digital health and social care; 29 June 2022. https://www.gov.uk/government/publications/a-plan-for-digital-health-and-social-care/a-plan-for-digital-health-and-social-care
[2] NHS Digital. 90% of NHS trusts now have electronic patient records; 16 November 2023. https://digital.nhs.uk/news/2023/90-of-nhs-trusts-now-have-electronic-patient-records
[3] Helen Jones. Electronic patient record systems: recurring themes arising from safety investigations. HSSIB; 19 December 2023. https://www.hssib.org.uk/news-events-blog/electronic-patient-record-systems-recurring-themes-arising-from-safety-investigations
[4] Alison Moore. Patient died and 30 harmed after new IT system launch. HSJ; 11 October 2023. https://www.hsj.co.uk/patient-safety/patient-died-and-30-harmed-after-new-it-system-launch/7035723.article
[5] NHS England. National Patient Safety Alert: Identified safety risks with the Euroking maternity information system; 7 December 2023. https://www.england.nhs.uk/wp-content/uploads/2023/12/NaPSA-Euroking-maternity-information-system-7-Dec-2023-FINAL.pdf
[6] Joe Talora. NHSE warns widely used EPR could pose ‘serious risks to patient safety’. HSJ; 8 December 2023. https://www.hsj.co.uk/technology-and-innovation/nhse-warns-widely-used-epr-could-pose-serious-risks-to-patient-safety/7036241.article
