National Patient Safety Alert: Identified safety risks with the Euroking maternity information system (7 December 2023)

Summary

Potential serious risks to patient safety have been identified with the use of Magentus Software Limited’s Euroking maternity information system. These concern specific data fields:

1. certain new patient information, recorded during a patient contact, can overwrite ('back copy') information previously recorded in the patient’s pregnancy record.
2. certain pregnancy-level data (information relevant only to a specific pregnancy event) can be saved at a patient level (where information relevant throughout a person's life is recorded), causing new information to overwrite (‘back copy’) previously recorded data across an entire patient record.
3. certain recorded pregnancy-level data can pre-populate into new pregnancy records (‘forward copy’), which can mean clinicians will see incorrect patient information, and attempts to correct this can result in the issue described at (ii) above.

Content

Actions

Organisations using Euroking:

1. must consider if Euroking meets their maternity service’s needs and ensure that their local configuration is safe. To do this they will need to work with their supplier to make changes to their existing system, and this will need to be overseen by their clinical safety officer.

2. must review and ensure that each data field within the system does not copy forward or backward.

3. if procurement of a new system is deemed necessary, organisations must ensure that all clinical information is appropriately backed-up, accessible for any future requirement and, when Euroking becomes a legacy system, must comply with action

Organisations with legacy Euroking contracts:

4. must implement a process to ensure users who access any legacy Euroking records will be alerted to the issues identified in this alert.

Organisations currently using another maternity information system/EPR:

5. must reassess the clinical safety of their maternity EPR with a suitably qualified clinical safety officer and, as a minimum, must ensure that the issues listed under ‘Additional information’ relating to the back and forward copying of information do not occur.

6. must assess that their current maternity EPR complies with the core maternity capabilities in the Maternity Digital Capabilities Framework.