Literature review on health IT-related patient safety incidents

Literature on the clinical safety of health information technology (HIT) systems is rapidly evolving as these systems roll out across the Australian health system. A literature review was carried out to identify appropriate methods for monitoring hazards affecting HIT systems and for investigating incidents resulting from the use of these systems.

The Commission asked the Australian Institute of Health Innovation at Macquarie University to perform a Literature review and environmental scan on approaches to the review and investigation of Health IT-related patient safety incidents.

Literature review results

The review found that the requirements for HIT safety systems are similar to those that apply to existing patient safety systems and should:

  • Include the ability to identify hazards ahead of time 
  • Permit review of incidents after the event
  • Provide information about the prevalence of incident reporting and management systems
  • Allow the opportunity to classify and report on incidents to ensure a continuous open loop of feedback and improvement.

The review noted that numerous methodologies exist and that no single method was appropriate to detect, investigate and classify all HIT incidents.  Successful HIT safety systems need to have in place a multidisciplinary team with appropriate skill sets from a clinical, health informatics and system safety perspectives and use a tailored approach to investigate HIT patient safety incidents.