“This is a MASSIVE clinical risk!!” – describing defects in health IT
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4 August 2014, by , in Blog, No comments

So you’ve identified a problem with your Health IT system and you know that it could contribute to clinical risk. What next? Often the most fruitful activity is to write it down ready for your risk assessment – carefully, unemotionally and objectively. Doing this brings together a clear understanding of the problem at that point in time and provides a basis for consulting or communicating with others about the degree of clinical risk and how it should be managed . It’s surprising how often, once the problem is written down, you find out that each stakeholder’s understanding of the issue is actually different.

So how do you go about doing this? A good starting point is context, context and more context. It’s always tempting when describing a defect to jump straight to the punchline; the blue button should be red, the page won’t load, the system throws an error. Ironically when it comes to assessing risk the physical manifestation of the problem is far less important than one might imagine. Instead it’s the impact that the issue has on our clinical workflow and the effect on patient care which causes us concern as clinicians.

One approach is to think about these questions:

  • What kind of user does the issue affect?
  • What is the user trying to do?
  • What does the user expect the system to do?
  • What is undesirable about the system behaviour?
  • How might the undesirable system behaviour impact a patient’s care?

Note that the structure provides no room for emotion or opinion; it’s just the plain old facts – nothing more. Another important consideration is an indication of the problem’s scale. Is this something that affects all users, all patients and all parts of the system or only when Dr Jones tries to look at Mrs Smith’s record? Frustrating as it might be for Dr Jones, in general terms, the greater the exposure of an issue the higher the risk.

Consider the following fictitious example:

“Ever since last week users haven’t been able to scroll the screen. Every time we try to look at a patient’s history the screen locks up and we can’t do anything about it. Last week it happened to me three times. We need to be able to see everything not just what happened last week. We are getting really fed up with this. If you ask me, this is a MASSIVE clinical risk!!!!! ”


“Clinical personnel need to review a patient’s clinical history. This requires the ability to review notes from a long time in the past. When a user navigates to the free-text history notes, the scroll bar cannot be moved so the information available is incomplete. The problem affects all users and began after a recent system upgrade. Failure to view historical clinical data could compromise clinical decision making.”

I am sure you would agree that the latter version provides a much more informed basis for undertaking an objective risk assessment.

So before you vent your frustration in an angry email to senior management take some time to describe the problem and remember that well-constructive objectivity is a far more powerful tool than the exclamation mark key.

Dr Adrian Stavert-Dobson is the Managing Partner of Safehand, independent consultants in clinical risk management, and the author of Health Information System: Managing Clinical Risk.

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