Clinical safety of England's national programme for IT: A retrospective analysis of all reported safety events 2005 to 2011

摘要

Objective: To analyse patient safety events associated with England's national programme for IT (NPfIT). Methods: Retrospective analysis of all safety events managed by a dedicated IT safety team between September 2005 and November 2011 was undertaken. Events were reviewed against an existing classification for problems associated with IT. The proportion of reported events per problem type, consequences, source of report, resolution within 24h, time of day and day 1of week were examined. Sub-group analyses were undertaken for events involving patient harm and those that occurred on a large scale. Results: Of the 850 events analysed, 68% (n = 574) described potentially hazardous circumstances, 24% (n = 205) had an observable impact on care delivery, 4% (n = 36) were a near miss, and 3% (n = 22) were associated with patient harm, including three deaths (0.35%). Eleven events did not have a noticeable consequence (1%) and two were complaints (＜1%). Amongst the events 1606 separate contributing problems were identified. Of these 92% were predominately associated with technical rather than human factors. Problems involving human factors were four times as likely to result in patient harm than technical problems (25% versus 8%; OR 3.98, 95%CI 1.90-8.34). Large-scale events affecting 10 or more individuals or multiple IT systems accounted for 23% (n = 191) of the sample and were significantly more likely to result in a near miss (6% versus 4%) or impact the delivery of care (39% versus 20%; p＜ 0.001). Conclusion: Events associated with NPfIT reinforce that the use of IT does create hazardous circumstances and can lead to patient harm or death. Large-scale patient safety events have the potential to affect many patients and clinicians, and this suggests that addressing them should be a priority for all major IT implementations.