In 2003 the NHS embarked
on a £12.4bn programme to introduce electronic patient
records in England. This involved the replacement of thousands
of existing systems with a range of new systems, coincidentally
creating the worlds largest ever data migration project.
The contract was based on the governments Private Finance
Initiative (PFI), under which, rather than get paid a capital
sum, suppliers are paid on the usage of the systems, and
thus they are heavily financially motivated to deliver systems
on time to optimise their revenue and minimise their cost.
An indication of the level of incentive is that one key
systems supplier was forced to pull out of their supply
contract having accumulated of £180m losses during
the first 2 years of engagement, whilst their subcontractor
has come close to bankruptcy.
Despite this, a hospital in the North East of England,
having conducted a fairly detailed range of acceptance tests,
went live with one of the new systems. Sometime later the
hospital discovered that, when certain icons on user interface
were used the system would generate erroneous data in the
form of changing appointment dates.
It is unclear as to what prompted the discovery of this
application error, but it was only discovered as a result
of what the Patient Safety Agency described as a "serious
incident".
Identification of Issue
Discovered as a result
of what the Patient Safety Agency described as a "serious
incident".
Cause
Coding error in application
development.
Implications to the Hospital
(and Patient)
Hospital - In a worse case scenario this error could
have resulted in serious implications to patient treatment
and safety, in which case the hospital, and potentially
its senior executives, could have been found liable in
a court of law. In a lesser circumstance this error might
simply have resulted in the hospital's resources being
wasted, i.e. if patient treatment resources were booked
for the wrong treatment dates.
Patient - In a worse case scenario, if this error was affecting
surgical appointment dates, for those suffering life threatening
conditions requiring surgery the implications could literally
have been fatal.
Solution
Issue Identification
Issue
Resolution
Issue Prevention
Taking into account the business process of the hospital,
a RAS Audit would have identified this logic error
DURING THE ACCEPTANCE TESTING of the new system,
BEFORE THE SYSTEM WAS USED IN PATIENT CARE, thus
preventing any risk of the error affecting live patient
information.
There are no solutions to preventing application errors.
Application errors are as likely to occur as a result of
an upgrade as they are when a system is first introduced,
and worse still, those that occur as a result of an upgrade
are the most likely to go unnoticed.
The only way to prevent the effects of an application error
is to identify it at the earliest possible time. Using RAS
Audit solutions as part of the acceptance testing procedure
for all new and upgraded applications will help identify
errors before they have any effect. A RAS
Monitor solution will help identify those that occur
as a result of viruses or as a result of integration with
other systems.
