The implementation of the Surrey Safe Care electronic patient record (EPR) at The Royal Surrey Foundation Trust and Ashford and St Peter’s Hospital Foundation Trust, saw a spike in safety reports filed, including one in which a patient died, and a further 30 that led to patients suffering some degree of harm.
Board reports for Royal Surrey revealed that there were 927 Datix incidents recorded as a consequence of Surrey Safe Care. Investigations concluded that one incident was catastrophic, two were severe, three involved moderate harm, and 25 incidents were low harm.
In addition, Ashford and St Peter’s reported a total of 269 Datix reports as a result of the Surrey Safe Care implementation. Three incidents were identified as moderate, and eight as low harm.
The catastrophic harm that led to a patient’s death was not “directly linked to technical problems” and “human factors” were also involved, including inexperience or unfamiliarity with the electronic prescribing system.
Louise Stead, chief executive of Royal Surrey, told HSJ: “Implementing an electronic patient record is a huge shift for any workforce and we experienced some issues with the functionality of the system and getting users sufficiently trained and confident in using it correctly. We have worked hard to address these issues as quickly and responsibly as possible.
“Our fundamental aim is for ‘zero harm’ and any harm caused to a patient is taken extremely seriously and invested. In the case of these Datix incidents the vast majority (over 99%) resulted in low or no harm to patients.
“However, one case resulted in the tragic death of a patient and we have been working closely with their family to be transparent and learn every possible lesson. This case was not directly linked to technical problems with the electronic patient record system and human factors did contribute. We are sincerely sorry for the failure in their care and devastating impact upon this person’s family.”
Following an investigation into the serious incident or a patient’s death, additional guidance and training for staff was given, reported HSJ. The trust is also working with Surrey Heartlands Integrated Care Board and NHS England to share its learnings.
Royal Surrey’s risk register stands at 20 – the highest possible rated risk.
HSJ readers reacting to the original story questioned how much time was spent on implementation of the system, while another placed the problem squarely at the trust leadership – and its inability to lead change.
Surrey Safe Care was jointly introduced to Royal Surrey and Ashford and St Peter’s in May last year. It ran until mid-September this year.
The EPR was provided by Cerner, which has since been acquired by Oracle, and rebranded as Oracle Health. Digital Health approached Oracle Health for comment, but they were unable to provide comment.
18 October 2023 @ 16:18
Seems very similar to the ongoing problems at the Department of Veteran’s Affairs in the U.S.–issues with Oracle-Cerner training, implementation, configuration and software workflows have lead to deaths and harm.
13 October 2023 @ 14:40
Unfortunately, human error will always exist.
Having previously used Cerner, I disagree with the previous poster. It was (then) definitely used as a workflow supporting tool. I try to keep in touch with developments across the board and seeing some of the planned AI direction of the monolithic providers – that is the only way to go.
My current Trust uses a “usable” mobile app. Usable to the sense it only completes about 5 tasks from a hospital of hundreds. It then creates a non-usable workflow having to flip between multiple systems. Irrespective of the handful of Twitter uses shouting from the rooftops, on the groud it is very different. AI isnt even a sparkle in their eye and they (and their clients) will be left high and dry with a usable mobile app that does about 5 things.
13 October 2023 @ 12:01
Cerner is a recording system, it just replaces paper. If you want to leverage that and add intelligent pathways, actions and automation and actually save your staff work and effort while managing the patients pathways you need an add on module such as “Lumeon” and then you’ll actually see some advantages