HSSIB’s latest report emphasises how Electronic Patient Record (EPR) systems still contribute to patient care being missed, delayed or recorded incorrectly. This is despite national recommendations and actions intended to reduce risks.
The report is a thematic review of HSSIB and its predecessor organisation, HSIB, investigations associated with EPR systems. The review aimed to identify where EPR systems had been considered in reports, the problems associated with them and their impact on patient safety. The review also revisited the safety recommendations and safety observations HSSIB had made that related to EPR systems.
The review highlights that EPR systems can improve patient care and support safety but that there are reoccurring issues with the design and implementation of the systems that can also create safety risks. Common issues include poor usability and interoperability between EPR systems and other software, outdated hardware and infrastructure affecting system performance, and limited resources to support the safe ongoing use of EPR systems.
HSSIB’s review gives specific examples of where EPR system problems have caused patient harm and had a detrimental impact on safety, on organisational efficiencies and on wider national efforts to digitise healthcare. The safety of patients was put at risk by EPR systems where they created conditions within which a patient did not receive care, their care was delayed, or they received incorrect care including from being misidentified. In a specific case referenced in the report, a four year old girl received 5 incorrect doses of blood thinning medication as the prescription was wrongly entered on the electronic prescribing and medicines administration (ePMA) system. The system did not identify the error and this incident contributed to bleeding around her brain.
To identify the common themes HSSIB reviewed all of its reports (2018 – 2025)., HSSIB identified recurring themes that illustrated how specific aspects of EPR systems may have contributed to patient safety issues. The themes are set out under three headings, with several key findings under each.
- Choosing an EPR system capable of meeting the needs of an organisation - where EPR systems did not have the functions an organisation needed or did not support the user (patients and staff), they had contributed to patient safety incidents.
- Implementing an EPR system that meets the needs of users - variation in governance processes for implementing EPR systems at national, regional and organisation levels meant associated risks to patient safety were not always identified and mitigated.
- Seeking feedback and ongoing EPR system optimisation - staff reported limited routes for raising concerns about poor functionality and usability of EPR systems, and limited action when concerns were reported that could impact on patient safety.
The review underscores the need for further action to strengthen digital safety. It also offers local learning prompts to support provider organisations in identifying and addressing risks associated with procuring, implementing and optimising EPR systems.
Nick Woodier, Senior Safety Investigator “Electronic patient record systems are a central part of modern healthcare and will only become more important as national digital ambitions continue to grow. This report is not a criticism of EPRs themselves; when implemented well, they can bring benefits for patient safety. However, the analysis of our past investigations shows that systems which are poorly implemented, difficult to use, or do not meet the needs of staff and organisations can introduce avoidable patient safety risks, which can contribute to serious harm.
“We note in the report that these issues persist despite national recommendations and concerted efforts to reduce the risks. Ultimately, this review is clear that effective, needs-led implementation is essential to ensure EPRs have a positive impact on safety – this will help close the gap between digital ambitions and the realities of frontline care.”
Following publication of the report, HSSIB is planning to launch further investigatory work in relation to EPR systems. This work will focus on the links between EPR systems when referring patients for specialist care, and on how EPR system loss or downtime is managed by organisations. Further information about these investigations will be made available on HSSIB’s website in the near future.
View the report at:
Patient safety issues associated with electronic patient record (EPR) systems – a thematic review
