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Investigation of incidents relating to digital health care.


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I am currently working to develop a new process for the investigation of incidents related to digital healthcare, something which clearly sits outside of the usual framework or process of investigating traditional patient safety incidents. I would be grateful for opportunities to discuss and share experiences and ideas with others. If you have already investigated these sort of incidents what sort of approach did you utilise and have you reviewed it post event in respect of effectiveness.

@Keith Bates Clive has suggested it would be beneficial for us to discuss?

2 reactions so far

Hi Gethin

Digital Healthcare is a bit broad and I will just refer to it as the "product".  You could consider 1.  Collection – search and obtain digital evidence and acquisition of data, consider use of audit logs to confirm actions of humans and systems and their behaviours. 2. Examination - applying techniques to identify and extract data this may require manufacturer reports or expert evidence of hardware/software.  3 Analysis – using data and resources to support case findings.  4. How this relates to other information gathered e.g. normal investigation methodology.  5. Reporting – presenting the info gathered (e.g., written case report) also consider areas such as e.g.: 

1.       Human reliability and error (one off or repetitive) interacting with the product

2.       Behaviours and attitudes e.g. human and product interaction

3.       Have human factors been built into systems engineering, effects of human factors and cognitive behaviour during interaction

4.       How the product was designed tested if bespoke and in house (external reporting from private companies)

5.       Method of input/output and the operations that form the process

6.       How the product fits into the safety culture

7.       Look at human centred design e.g. through the life cycle

8.       User experience 

It may be difficult to build a one size fits all, perhaps some broad strokes e.g. first para and then focus points on the product involved, e.g. IPad and software used for community nursing on home visits.

Hope this of some help and happy to advise where I can





2 reactions so far

Morning Keith, many thanks for your response it has certainly helped me focus some of my thoughts, and yes as I progress my workstream I would certainly value the opportunity to discuss further.

Kind regards


1 reactions so far

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