Additional data tables and analysis not included in the main 2025 Annual SHOT Report.
WBIT in non-maternity cases n=593
Sample labelling
The details of the sample taking and labelling processes were provided in 557/593 (93.9%) cases. The WBIT sample was handwritten in 471/557 (84.6%) cases and labelled using an electronic information technology (IT) system in 86/557 (15.4%).
Involvement of IT
IT was identified as a contributory factor in 106/553 (19.2%) cases with selecting the wrong patient from the IT system and system not used correctly the most common errors (Table 16a.3). In 75 WBIT, it was noted that the use of IT could have prevented the error. The main themes from these were:
- IT system in place but not used mainly because staff were not trained or did not have access to the IT system
- IT system not in place and no plans for implementation due to lack of funding
- Implementation or upgrade of the IT system as part of the corrective and preventative actions (CAPA)
Table 16a.3: The impact of IT systems reported in non-maternity WBIT (n=181)
| The involvement of IT in the non-maternity WBIT | Sample handwritten | Sample labelled electronically | Total |
|---|---|---|---|
| Incorrect patient details selected from the IT system | 32 | 14 | 46 |
| IT system not used correctly | 9 | 19 | 28 |
| Printing error | 6 | 4 | 10 |
| Computer or IT system failure | 5 | 4 | 9 |
| IT system not configured correctly | 4 | 4 | 8 |
| Lack of functionality/ algorithms in the IT system to support safe practice | 1 | 1 | 2 |
| Lack of interoperability | 2 | 0 | 2 |
| Failure to use flags and/or logic rules | 1 | 0 | 1 |
| IT could have prevented the error | 72 | 3 | 75 |
| Total | 132 | 49 | 181 |
WBIT in maternity cases n=399
Sample labelling
The details of the sample taking and labelling processes were provided in 375/399 (94.0%) cases. The WBIT sample was handwritten in 339/375 (90.4%) cases and labelled electronically in 42/375 (11.2%).
Involvement of IT
IT was identified as a contributory factor in 137/399 (34.3%) cases. Selecting the wrong patient from the IT system was the highest category accounting for 34 WBIT (Table 16a.4). Other common factors were system not used correctly, computer or IT system not functional at the time of the event or not configured to promote safe practice. In 43 reports the IT could have been prevented the error associated with similar main themes as for non-maternity cases:
- Implementation of the IT system as part of the CAPA
- IT system in place but not used mainly because staff were not trained or did not have access to the IT system
- IT system not in place and no plans for implementation due to lack of funding
Table 16a.4: The impact of information technology systems reported in WBIT maternity (n=137)
| The involvement of IT in the maternity WBIT | Sample handwritten | Sample labelled electronically | Total |
|---|---|---|---|
| Incorrect patient details selected from the IT system | 29 | 5 | 34 |
| IT system not used correctly | 6 | 9 | 15 |
| Printing error | 11 | 3 | 14 |
| IT system not configured correctly | 8 | 3 | 11 |
| Computer or IT system failure | 8 | 2 | 10 |
| Lack of functionality/ algorithms in the system to support safe practice | 0 | 3 | 3 |
| Lack of interoperability | 2 | 0 | 2 |
| Failure to link, merge or reconcile computer records | 1 | 0 | 1 |
| Incorrect results entered or accessed manually | 1 | 0 | 1 |
| IT could have prevented the errors | 42 | 1 | 43 |
| Total | 111 | 26 | 137 |