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This national patient safety alert has been issued by the NHS England National Patient Safety team. This alert is for action by acute, community and mental health providers, health and justice services, primary care including nursing and care homes, general practice and community pharmacy. All actions should be completed as soon as possible but no later than 20 November 2026. This alert has been issued in response to concerns of patients with penicillin allergies being incorrectly recorded as a penicillamine allergies in electronic prescribing systems. This creates a risk of a patient with a known penicillin allergy being administered a penicillin-based antibiotic and having a potentially fatal anaphylactic reaction. The risk of this error is not specific to any one electronic prescribing system. Actions required At health system level Primary and secondary care organisations should form a working group across an appropriate geographical area, chaired by an appropriate chief clinical information officer, to co-ordinate implementation of the following actions: Identify patients recorded as having a penicillamine allergy by running a report in relevant digital systems in primary and secondary care. Clinically review the accuracy of the allergy status and amend accordingly. Ensure allergy records in electronic prescribing and related digital systems that record allergy status are updated. To prevent reoccurrence: Secondary care organisations should ensure allergy guidance and training cover safe recording of allergy status in electronic prescribing systems and related digital healthcare systems, including the need to check and correct allergy status on admission and discharge. Primary care should implement additional checks when staff (especially non-clinical staff) input allergy status into GP systems, for example, consider the need for a clinical review if penicillamine is the stated allergen. All organisations should work with digital system suppliers and user groups to develop and deploy additional built-in mitigations to reduce the likelihood of inadvertent recording of the wrong allergy, such as adding alerts and modifying search terms. Organisations should prioritise the safe deployment of upgrades to their digital systems where suppliers have developed effective mitigations and safety features. The working group should strongly consider producing regular reports on allergy status until assurance has been gained that the issue is resolved.

In this article for the Journal of mHealth, Victoria Betton looks at the importance of a user-centred design approach to developing electronic patient records (EPRs). She highlights four key principles, based on human factors, that should be considered when designing an EPR: Start early with user needs—take time to build user needs and goals into your thinking from the start of your business case and keep them at the core of your requirements. Use observation, interviews and analysis of data (for example, clinical incident reports) to give you the insights you need. Bake in adoption from the get-go—make sure there is sufficient resource and time in the business case to engage and involve EPR users at each stage of the process, from defining needs through to procurement, implementation and ongoing optimisation over time. Get it right before you configure—use wireframes and simulation to test out before you start to configure the EPR. Make it as easy as possible for users to enter data in the right place the first time. Iterate—create a process that allows for ongoing iteration, learning and optimisation of the EPR. Don’t send floor walkers in for two weeks and ask them to leave. Ongoing adaptation and improvement are key.

The introduction of the electronic health record was heralded as a technology solution to improve care quality and efficiency, but these tools have contributed to increased administrative burden and burnout for clinicians. Today, artificial intelligence is receiving much of the same attention and promises as electronic health records. Can healthcare learn from the failures of electronic health records to maximise the potential of artificial intelligence?

Electronic health record (EHR) nudges are a common way to subtly change clinician behaviour (e.g., prompt for immunisations). This review summarizes the association between EHR nudges and health outcomes in primary care. Results show nudges improve specific aspects of healthcare quality, but most studies reported only process measures—whether the nudge was accepted— not the impact on patient safety.

Hospitals rely on their electronic health record (EHR) systems to help them provide safe, high quality and efficient health care. However, EHR systems have been found to disrupt clinical workflows and may lead to unintended consequences associated with patient safety. This study sought to explore the differences in staff perceptions of the usability and safety of their hospital EHR system by staff position and length of service. The authors found significant differences in results across staff positions and hospital tenure: In comparison to registered nurses, pharmacists had significantly lower scores for EHR system training. Doctors, hospital management and IT staff were significantly more likely to report high frequency of inaccurate EHR information. Compared to staff with 11 or more years of hospital tenure, new staff had significantly lower scores for EHR system training, but higher scores for EHR support & communication. Dissatisfaction with the EHR system was highest among doctors and staff with 11 or more years tenure at the hospital.

New research has revealed what is hampering digital adoption across the NHS, as leaders look to unlock the full potential of technology and usher in the digital revolution. A survey, conducted by NHS Providers, indicates that everything from financial constraints, day-to-day pressures, and obsolete IT infrastructure are hamstringing the health service. This blog from the National Health Executive looks at the barriers, the current digital capability and the next steps.

University Hospital Derby and Burton NHS Trust (UHDB) partnered with TPXimpact to make an informed choice in procuring the right electronic patient record system for the Ophthalmology team and make recommendations on implementing it successfully.

This toolkit provides information about how the US Department of Health and Human Services Office of the Director General conducted recent medical record reviews to identify patient harm. It outlines the decision criteria for adverse events and describes the methods used in the report, 'Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm' in October 2018, building upon a broader series of reports about adverse events in hospitals and other health care settings.

The Digital Medicines Transformation Portfolio aims to use digital technologies to make prescribing, dispensing and administering medicines everywhere in Wales, easier, safer and more efficient for patients and professionals. It brings together the programmes and projects that will deliver a fully digital prescribing approach in all care settings in Wales. This video outlines the different elements of the portfolio that will be introduced across primary and secondary care, including the Shared Medicines Record, which will store information about a patient's medications all in one place.

Poorly designed electronic health records (EHRs) are common, and research shows poor design consequences include clinician burnout, diagnostic error, and even patient harm. One of the major difficulties of EHR design is the visual display of information, which aims to present information in an easily digestible form for the user. High-risk industries like aviation, automotive, and nuclear have guidelines for visual displays based on human factors principles for optimised design. In this study, Pruitt et al. reviewed the visual display guidelines from three high-risk industries—automotive, aviation, nuclear—for their applicability to EHR design and safety.

The NHS’s deal with the US tech company Palantir raises privacy concerns, but a unified database could be a medical gamechanger writes Martha Gill in an article for the Observer. Governments have been trying to stitch together our patchwork system for decades. Billions have been lost in these attempts. However, they always run up against the same problem: people just don’t want to share their medical data, even when assured it will be anonymised. When the government aimed to build a collection of anonymous GP health records, around a million patients opted out. The latest of these attempts has closed a loophole: patients cannot now opt out. But this has enraged civil liberties groups, which are concerned about the company chosen to merge, clean and provide tools for sorting through the data.

Patients who visit their GP practice with an ongoing health problem may see several different GPs about the same symptoms. To make sure they receive safe and efficient care, there needs to be a system in place to ensure continuity of care. In the context of this report, continuity of care is where a patient has an ongoing relationship with a specific doctor, or when information is managed in a way that allows any doctor to care for a patient. While some GP practices in England operate a formalised system of continuity of care, many do not. This investigation explored the safety risk associated with the lack of a system of continuity of care within GP practices. The investigation focused on: How GP practices manage continuity of care. This includes how electronic record systems alert GPs to repeat attendances for symptoms that are not resolving and how information is shared across the healthcare system. Workload pressures that affect the ability of GP practices to deliver continuity of care. This investigation’s findings, safety recommendations and safety observations aim to prevent the delayed diagnosis of serious health conditions caused by a lack of continuity of care and to improve care for patients across the NHS. Reference event Brian had a history of breast cancer and had been discharged from the breast cancer service. Two years later he began to have back pain. Initially the pain was so severe that Brian visited his local emergency department (ED). He was discharged from the ED with pain relief and was advised to contact his GP practice. A month later, Brian telephoned his GP practice and saw his named GP. The GP referred Brian to the GP practice’s physiotherapist and requested a blood test. Brian saw the physiotherapist, who gave him advice about exercises to help relieve the back pain. The exercises did not relieve Brian’s pain and over the following 8 months he saw two out-of-hours GPs and six practice GPs, a nurse and a physiotherapist at the GP practice. Brian also had consultations with healthcare professionals during this time for other conditions not relating to his back pain. When Brian saw a GP at end of the 8-month period, the GP found a lump on his spine and advised Brian to go to the local ED. At the ED, Brian had a computerised tomography (CT) scan. A lump was found on his spine which was later diagnosed as metastatic breast cancer (that is, breast cancer that had spread to his spine). Findings The GP contract, which sets out the mandatory requirements for GP services commissioned by the NHS, does not specifically require GP practices to adopt an approach that ensures continuity of care, but practices can do so voluntarily. Many GP practices do not operate a formalised system of continuity of care. There is no standard framework to deliver continuity of care in GP practices, so it is done differently across the country. Many GPs understand the benefits of continuity of care; however, some practices did not believe that it was possible to deliver such a system. Other practices were able to maintain continuity of care through systems developed by those practices. There is no requirement for GP IT systems to consider continuity of care or to ‘surface’ information (that is, identify and flag up relevant patient information) to GPs when they see a patient with unresolving symptoms. Patients told the investigation that they found it beneficial to see their named GP for long-term health conditions, including mental health conditions. GPs working in a practice with a system of continuity of care had more time to process information during consultations and to carry out any follow-on actions to ensure patients received the care they needed. GP practices that operated a system of continuity of care reported to have better staff welfare and retention, and fewer recruitment issues, than those that did not. Safety recommendations HSSIB recommends that the Department of Health and Social Care ensures that the GP contract explicitly includes and supports the need for GP practices to deliver continuity of care. This is to improve patient safety by building clinician–patient relationships as well as providing continuity of information. HSSIB recommends that NHS England updates the GP IT standards to ensure that patient continuity of care is maintained, including the identification and prioritisation (technically known as ‘clear surfacing’) of information to health and care professionals, when patients visit GP practices multiple times with unresolving symptoms. Safety observation GP practices can improve patient safety by aligning their staff wellbeing and patient safety policies to those of NHS England’s proposed patient safety strategy.

Retrospective chart review is the standard for estimating prevalence of adverse events. Manual review of the electronic health record (EHR) is resource intensive. This study from Garzón González et al. describes the construction and validation of electronic trigger set, TriggerPrim, to rapidly identify charts with potential adverse events in primary care. The resulting set has five triggers: ≥3 appointments in a week at the PC center, hospital admission, hospital emergency department visit, prescription of major opioids, and chronic benzodiazepine treatment in patients 75 years or older. Use of TriggerPrim reduced time in the EHR by half.

The aim of this investigation and report is to help improve the inpatient care of adults with a known learning disability in acute hospital settings. It focuses on people referred urgently for hospital admission from a community setting, such as a person’s home or residential home. In undertaking this investigation, the Health Services Safety Investigations Body (HSSIB) looked to explore the factors affecting: The sharing of information about people with a learning disability and their reasonable adjustment needs following admission to an acute hospital. How ward-base staff are supported to delivery person-centred care to people with a learning disability. Reference event The investigation used as a reference event a patient safety incident involving a 79-year-old man who was recorded on his GP’s learning disability register as having a mild learning disability. After being admitted to hospital due to his worsening health. Throughout the patient’s stay, up to his death following a cardiac arrest, his individual needs were not always identified and reasonable adjustments to meet his care needs were not always made. Findings The health and care system is not always designed to effectively care for people with a learning disability. People with a learning disability who are admitted to an acute hospital are often cared for by staff without specialist training, skills and experience in working with people with a learning disability. These staff often have limited support and are unable to take the time they would like to meet the person’s needs. There is no standard model or national guidance for an acute learning disability liaison service (that is, teams that are specifically trained in caring for people with a learning disability). Consequently, there is variation in how these services are funded, their availability, the size of teams and what they are expected to do. The quality of learning disability services is currently monitored via the learning disability improvement standards annual benchmarking survey which is funded until the end of 2023/24. Decisions on future years have yet to be made. Staff in acute hospitals may lack confidence and support in assessing the mental capacity of people with a learning disability, in line with the Mental Capacity Act (2005). There is no national shared system with a single point of access for storing and managing information about the needs of people with a learning disability and the reasonable adjustments required for each individual. Current mechanisms for sharing information about a person – such as ‘care passports’ (a document that gives staff helpful information about the person’s health and social needs, including their preferred method of communication, likes and dislikes) and alert flags (a way to highlight key information to staff) on the electronic patient record – can be unreliable. Instead, information is often gathered from friends and family. Evidence exists that people with a learning disability experience health inequities. Long-held societal beliefs about the abilities of people with a learning disability may influence the provision of and decisions made around their care. Safety recommendations As a result of this investigation, HSSIB recommended that NHS England should: Develops and issues learning disability liaison nursing service best practice and workforce guidance to all acute hospitals. This is to help local decision making about specialist learning disability provision and enable appropriate support for people with a learning disability and the staff who care for them. Ensure that the national learning disability improvement standards annual benchmarking survey for the care of people with a learning disability is continued for acute hospitals in order to help assure that local population needs are met. Commission the development and dissemination of guidance on the practical assessment of the mental capacity of people with a learning disability in acute hospitals. This is to ensure that appropriate decisions are made about the person’s care. With support from key stakeholders including the Professional Record Standards Body, work collaboratively to develop and publish a set of guidelines on information to be included in a health and care passport (which could be paper based, digital, or both) for people with a learning disability with consideration of the reasonable adjustments that people may need. This is to ensure the most current and accurate information about reasonable adjustments to the person’s care is accessible when and wherever it is needed. Safety observations HSSIB made four safety observations as a result of this investigation: Health and care providers can improve patient safety by ensuring that local configuration of electronic patient record systems consider the accessibility and usability of the digital record reasonable adjustments flag in patient records. Health and care curricula can improve patient safety by aligning with the national code of practice on statutory learning disability and autism training, when finalised. Health and care providers can improve patient safety by advocating for all people with a learning disability to have an up-to-date care passport.

The importance of big health data is recognised worldwide. Most UK National Health Service (NHS) care interactions are recorded in electronic health records, resulting in an unmatched potential for population-level datasets. However, policy reviews have highlighted challenges from a complex data-sharing landscape relating to transparency, privacy, and analysis capabilities. In response, authors of this study, published in The Lancet Digital Health, used public information sources to map all electronic patient data flows across England, from providers to more than 460 subsequent academic, commercial, and public data consumers. Although NHS data support a global research ecosystem, they found that multistage data flow chains limit transparency and risk public trust, most data interactions do not fulfil recommended best practices for safe data access, and existing infrastructure produces aggregation of duplicate data assets, thus limiting diversity of data and added value to end users. They provide recommendations to support data infrastructure transformation and have produced a website to promote transparency and showcase NHS data assets.

This article published by the Betsy Lehman Center looks at the benefits of real-time monitoring of electronic health records (EHRs). Early adopter hospitals have demonstrated dramatic gains in safety by monitoring patients' EHR's in real time for signals of potential safety events, allowing providers to more quickly and effectively address safety gaps and improve outcomes. This monitoring is carried out by automated safety surveillance software that continuously runs in the background of EHR systems and can detect hundreds of categories of adverse events as they occur. Expert analysis then quickly helps organisations gain insight from the data, which can be used to proactively reduce safety risks and reliably measure incidence of harm over time.

Recent polling from Healthwatch England shows that a fifth of patients referred by a GP for consultant-led care end up in a ‘referral black hole’, with more than two million patients each year having to make four or more visits to their GP before a referral is accepted. The result is that tens of thousands of patients could be on a ‘hidden’ waiting list, meaning that GPs are managing greater clinical risk and a greater number of patients whose conditions are often worsening in primary care, whilst communication between providers and access to diagnostics are often not up to scratch.  This report by the think tank Policy Exchange looks at reforms that could be made to the interface between primary and secondary care in order to improve care and prevent patient harm. It considers how improved flows of information and expertise can: better support growing demand in general practice reduce unwarranted variation in service provision enhance care coordination – particularly for those referred for elective procedures enable opportunities to boost generalist medical skills for a new generation of doctors create opportunities for hospital specialists to deliver a greater proportion of care in primary or community care settings, reducing waiting times and the use of more expensive settings for care.

Patients and families are key partners in diagnosis, but there are few methods to routinely engage them in diagnostic safety. Policy mandating patient access to electronic health information presents new opportunities, and in this study, researchers tested a new online tool—OurDX—that was codesigned with patients and families. The study aimed to determine the types and frequencies of potential safety issues identified by patients with chronic health conditions and their families and whether their contributions were integrated into the visit note. The results showed that probable Diagnostic Safety Opportunities (DSOs) were identified by 7.5% of paediatric and adult patients with underlying health conditions or their families. Among patients reporting diagnostic concerns, 63% were verified as probable DSOs. The most common types of DSOs were patients or families not feeling heard, problems or delays with tests or referrals and problems or delays with explanation or next steps. In chart review, most clinician notes included all or some patient/family priorities and patient-reported histories. The researchers concluded that OurDX can help engage patients and families living with chronic health conditions in diagnosis. Participating patients and families identified DSOs and most of their OurDX contributions were included in the visit note.

The SAFER Guides are designed to help healthcare organisations conduct self-assessments to optimise the safety and safe use of electronic health records (EHRs). Each of the nine SAFER Guides begins with a Checklist of “recommended practices.” This Patient Identification SAFER Guide identifies recommended safety practices associated with the reliable identification of patients in the EHRs. Accurate patient  identification ensures that the information presented by and entered into the EHR is associated with the correct person. Processes related to patient identification are complex and require careful planning and attention to avoid errors. The SAFER Guides are produced by The Office of The National Coordinator for Health Information Technology.