NHS trusts have reported nearly 300 incidents that put
patients' safety at risk since 2005, when theNational Programme for ITbegan
systematic records.
The disclosure provides evidence that new IT systems in the
health service can put the safety and health of patients at risk if
they fail or are used wrongly.
Maureen Baker, national lead for clinical safety at
NHS Connecting for
Health, revealed the incidents at a conference in
Harrogate.
"We have had just under 300 incidents in two and half years,"
she said. "They cover just about every area that CfH has activity
in."
It has also emerged that ministers launched the NPfIT in 2002
with no formal structure for identifying incidents that could
affect patient safety.
Many of the incidents reported under the safety scheme centre on
radiology information systems and
picture archiving and communication systems (Pacs), which allow
digital X-ray images to be stored, retrieved and distributed to
computer screens.
One incident involved two NHS trusts that had connected Pacs
systems. Both used similar ID numbers to store and retrieve images,
but some numbers were duplicated, so sometimes a correct number
would retrieve the wrong X-ray image.
There have also been incidents of drugs "mis-mapping", which
could lead to the wrong drugs being given, or a clash of medication
occurring.
NHS Connecting for Health, which runs part of the national
programme, put a new structure for reporting incidents into place
only after DNV consulting compiled a highly critical - and
unpublished - risk assessment of the safety of the NPfIT in
2004.
Speaking at the
HC2008 conference, Baker said there had been a big improvement
in mechanisms for reporting incidents and dealing with them since
2005, three years after the launch of NPfIT.
"Of the incidents we have dealt with, we are not aware of a
patient actually being harmed," she said. "It is very much the
potential of being harmed. We looked to see if anyone has been
harmed. We have not identified yet that that has been the case.
"We are able to detect when something goes wrong in any of the
systems and quickly pick that up, address it and make it safe."
Last year the partner of a patient who died in hospital
complained to the General Medical Council that X-rays on a Pacs
system may have been mixed up. She told Computer Weekly she is
waiting for a date for a judicial review over whether there should
be a fresh inquest.
It is not known whether this was one of the 290 incidents that
put patients' safety at risk.
The annual healthcare IT conference at Harrogate is organised by
the British Computer Society.
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