SCRIPT articles
SHOT UK Collaborative Reviewing and Reforming IT Processes in Transfusion (SCRIPT) survey: Laboratory information management systems: Are we ready for digital transformation? has now been published in Transfusion Medicine.
The published article can be accessed via the Wiley online library.
Problem statement due to transcription errors in IT systems
It has been recently brought to the attention of SHOT that a UK maternity patient data management system allows clinical staff to manually input patient pathology and other test results into the system. This may impact decisions related to patient care including blood group, red cell antibody screen and identification results. Other clinical systems that use pathology data may be similarly impacted.
This communication is to help improve awareness of this issue and to prompt necessary actions to improve patient safety. Some initial actions are suggested in document below.
Problem-Statement-transcription-errors-in-IT-systems (254kB pdf)
System level actions such as automation and interfaces that negate the need for any manual transcription and should be implemented where possible. Where this is not fully implemented, the following actions are recommended to enhance safety:
- Review clinical IT systems interfaced to the laboratory information management system (LIMS)
to identify those where manual entry of results is also available and/or required. Ensure adequate
mitigation is in place to reduce the risk of transcription errors. Where possible, electronic systems
should be configured to prevent manual entry of pathology results by clinical teams - User awareness and training – Please inform users in your organisations about the potential for
transcription errors during manual data entry and the potential impact of these errors. Provide
targeted training to reinforce best practices - Risk assessment- Perform a thorough risk assessment focusing on areas where transcription errors
are most likely to occur, capture mitigations in place and any further actions required - Regular audits- Schedule regular audits of manual data entries to identify failures in current risk
mitigations and address further actions - Haemovigilance reporting- Please ensure timely reporting to SHOT and MHRA of any relevant
transfusion incidents - Reporting to Yellow Card as appropriate
- Escalating concerns to IT supplier
- Ensure feedback loops are in place so that users can report issues
- Record on organisation risk register and escalate concerns to senior leadership teams. It is
important to note that where the MHRA find errors threatening data integrity that the laboratory is not in control of, this may affect the regulatory status of the laboratory which the Chief Executive of the hospital is responsible for