Patient died and 30 harmed after new IT system launch

A trust saw nearly 1,000 safety reports filed after introducing a new electronic patient record (EPR) – including one where a patient died and 30 others where they suffered harm.

The Royal Surrey Foundation Trust and Ashford and St Peter’s Hospital Foundation Trust installed a new joint EPR system in the middle of last year.

But Royal Surrey’s board was told there had been 927 Datix reports — which are used to raise safety concerns — related to the introduction of the “Surrey Safe Care” system, running up until mid September this year.

The catastrophic harm involved a patient death which the trust says was not “directly linked to technical problems” with the EPR, as “human factors” were involved, including inexperience or unfamiliarity with the electronic prescribing system.

Louise Stead, chief executive of Royal Surrey, said: “Implementing an electronic patient record is a huge shift for any workforce and we experienced some issues with the functionality of the system and getting users sufficiently trained and confident in using it correctly. We have worked hard to address these issues as quickly and responsibly as possible.

“Our fundamental aim is for ‘zero harm’ and any harm caused to a patient is taken extremely seriously and investigated. In the case of these Datix incidents the vast majority (over 99%) resulted in low or no harm to patients.

“However, one case resulted in the tragic death of a patient and we have been working closely with their family to be transparent and learn every possible lesson. This case was not directly linked to technical problems with the electronic patient record system and human factors did contribute. We are sincerely sorry for the failure in their care and devastating impact upon this person’s family.”

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Source: HSJ, 11 October 2023