Prioritise patient safety in design and rollout of EPR systems: report

A new report from Patient Safety Learning, a charity and independent voice for improving patient safety, has called for changes to the process of developing and rolling out electronic patient record (EPR) systems, emphasising greater prioritisation of patient safety and experience. The report, Electronic patient record systems: Putting patient safety at the heart of implementation, is based upon the observations and insights from a group of experts convened for a roundtable in June 2024 by Patient Safety Learning.

EPR systems collate patient data, including medical history, test results, clinicians’ observations and prescribed medications, from various sources, making it easier for healthcare professionals to access patient information. EPRs can vary from covering a single GP surgery, a single specialty area, or multiple areas within an NHS Trust serving hundreds of thousands of patients.

Their introduction into the NHS was identified as a key priority in the Department for Health and Social Care’s 2022 policy paper, A plan for digital health and social care, and as of November 2023, 90 per cent of NHS trusts had introduced an EPR.

However, the report outlines that there are significant patient safety risks associated with planning, implementing and using EPRs, as well as concerns around incident reporting.

The report explores several instances where avoidable harm has occurred due to poor implementation or usage of EPR systems. These include an example where a four-year-old received 10 times the intended dose of a coagulant on five separate occasions due to an undetected prescription error recorded on a medicines EPR system. Another incident, which resulted in a National Patient Safety Alert being issued in 2023, occurred when an EPR system being used in the maternity departments of at least 15 NHS trusts was found to be overwriting existing patient record data with new information and displaying incorrect safeguarding data, putting maternity patients at risk.

In another case from February 2024, a Coroner’s Prevention of Future Deaths report highlighted how a new EPR system contributed to the death of Emily Kate Harkleroad, a 31-year-old woman who died of a pulmonary embolism after delays in treatment at Country Durham and Darlington NHS Foundation Trust. The report found that “errors and delays in [her] medical treatment resulted in her not receiving the anticoagulant treatment that she needed, and which would, on a balance of probabilities, have prevented her death.”

The report offers ten principles for consideration for the safe implementation of EPR systems:

• There should be robust standards for ensuring safety in EPR implementation and operationalisation. These standards should be accompanied by strong quality assurance and accountability mechanisms.
• Patients should be engaged and involved in each stage of the implementation and delivery of EPR systems.
• EPR system implementations should be planned and delivered as major organisational change programmes, not simply technical IT projects.
• Healthcare professionals and those who will be the primary users of EPR systems should be involved in each stage of their design, planning and implementation.
• There should be Board-level and senior leadership champions for EPR implementation programmes. These staff should be properly trained and experienced with the expertise to guide, support, and if necessary, challenge.
• Communities of practice in EPR system implementation should be established to share knowledge, provide support and access to guidance.
• Human factors experts should have a central role in EPR implementation, from design through to product selection and operationalisation.
• Clinical Safety Officers, who play a key role in the success of EPR implementations, need to be expertly trained, resourced and supported.
• Incident reporting and investigations should capture EPR-related safety issues and this should inform improvement in the future design and implementation of EPR systems.
• Learning from EPR implementations should be shared transparently and widely across the healthcare system to ensure that risks are mitigated and managed, and to inform safety improvements. This relates to both NHS and independent sector organisations as well as with suppliers and procurement staff.

Commenting on the report, Patient Safety Learning Chief Executive, Helen Hughes, said: “EPR systems have significant potential to improve patient care and treatment. However, we are increasingly seeing cases where poor implementation of these new systems results in direct and indirect harm to patients. If we are to fully realise their benefits, patient safety must be at the heart of their design, development and rollout.

“To ensure the safety of EPR systems, it is vital that patient safety incidents associated with them are reported and acted upon. We need more transparency in reporting and sharing knowledge, of both errors and examples of good practice.

“We hope that this report can kick off an informed and transparent debate about these issues, leading to action that supports the safer implementation of EPR systems and reduces avoidable harm.”

The full report can be accessed here.