title: Clinical safety of England's national programme for IT: a retrospective analysis of all reported safety events 2005 to 2011.
abstract: OBJECTIVE
  To analyse patient safety events associated with England's national programme for IT (NPfIT).
  
  
  METHODS
  Retrospective analysis of all safety events managed by a dedicated IT safety team between September 2005 and November 2011 was undertaken. Events were reviewed against an existing classification for problems associated with IT. The proportion of reported events per problem type, consequences, source of report, resolution within 24h, time of day and day of week were examined. Sub-group analyses were undertaken for events involving patient harm and those that occurred on a large scale.
  
  
  RESULTS
  Of the 850 events analysed, 68% (n=574) described potentially hazardous circumstances, 24% (n=205) had an observable impact on care delivery, 4% (n=36) were a near miss, and 3% (n=22) were associated with patient harm, including three deaths (0·35%). Eleven events did not have a noticeable consequence (1%) and two were complaints (<1%). Amongst the events 1606 separate contributing problems were identified. Of these 92% were predominately associated with technical rather than human factors. Problems involving human factors were four times as likely to result in patient harm than technical problems (25% versus 8%; OR 3·98, 95%CI 1·90-8.34). Large-scale events affecting 10 or more individuals or multiple IT systems accounted for 23% (n=191) of the sample and were significantly more likely to result in a near miss (6% versus 4%) or impact the delivery of care (39% versus 20%; p<0·001).
  
  
  CONCLUSIONS
  Events associated with NPfIT reinforce that the use of IT does create hazardous circumstances and can lead to patient harm or death. Large-scale patient safety events have the potential to affect many patients and clinicians, and this suggests that addressing them should be a priority for all major IT implementations.
authors.affiliation: Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, Australia. Electronic address: farah.magrabi@mq.edu.au.
authors.forename: Farah
authors.initials: F
authors.lastname: Magrabi
authors.affiliation: Health and Social Care Information Centre, Leeds, England.
authors.forename: Maureen
authors.initials: M
authors.lastname: Baker
authors.affiliation: Oxford University NHS Trust, England.
authors.forename: Ipsita
authors.initials: I
authors.lastname: Sinha
authors.affiliation: Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, Australia.
authors.forename: Mei-Sing
authors.initials: MS
authors.lastname: Ong
authors.affiliation: Health and Social Care Information Centre, Leeds, England.
authors.forename: Stuart
authors.initials: S
authors.lastname: Harrison
authors.affiliation: Faculty of Medicine, Nursing and Health Sciences, Flinders University, Australia.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Kidd
authors.affiliation: The School of Psychology, Social Work & Social Policy, University of South Australia, Australia; Australian Patient Safety Foundation, Adelaide, Australia.
authors.forename: William B
authors.initials: WB
authors.lastname: Runciman
authors.affiliation: Centre for Health Informatics, Australian Institute of Health Innovation, Macquarie University, Australia.
authors.forename: Enrico
authors.initials: E
authors.lastname: Coiera
mesh_terms: D020000:Decision Support Systems, Clinical; D003695:Delivery of Health Care / Q000379:methods* / Q000592:standards; D057286:Electronic Health Records; D004739:England; D019544:Equipment Failure Analysis / Q000706:statistics & numerical data*; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008490:Medical Informatics / Q000592:standards / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012308:Risk Management; D017751:Safety Management; D013222:State Medicine; D014584:User-Computer Interface
keywords: Computer systems; Equipment failure analysis; Medical errors/statistics and numerical data; Risk management/classification; User-computer interface