Surrey Safe Care EPR led to “catastrophic” harm incident

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.