Facilitator Handbook 2005 - PRIMIS

PRIMIS Facilitator Handbook
Data Quality and Patient Safety
The stakeholder interviews also identified other areas of concern with current clinical systems
and their usage:
The Training
• the need for a drug dictionary for the NHS to improve communication between
systems
• the need for drug ontologies that provide sensible alerts and decision support
• the need to develop audit trails
• ensuring that account is taken of human ergonomics in the design of computerised
alerts
• the need for healthcare staff to be trained in the safe and effective use of systems
• the need to produce safety specific regulations, requirements and guidelines
• the need to build a safety culture and raise safety awareness in primary care.
The NPSA commissioned PRIMIS to develop a training module for information facilitators. The
training takes place over a full day and is run on a group workshop basis. It includes
presentation of the research findings and discussion around the following topics:
Known clinical system features and problems
• Hazard alerts for contraindicated drugs, drug interactions, allergies, frequency of
dose and the need for monitoring
• Safety checks for repeat prescribing
• Decision support software
• Avoiding spurious or irrelevant alerts
• Avoiding overriding critical alerts
• The use of audit trails
• Call and recall systems for patient monitoring
• Alerts for missed referrals and abnormal results
• The effect of poor-quality data on the effectiveness of safety features
All the currently used systems have a number of in-built warning messages that are designed
to alert the user to a potential hazard if the chosen course of action is pursued. Unfortunately,
these messages are of differing sensitivity, appearance, visibility and reliability.
Other areas where data quality can affect patient care
• Tracking if patients attended referral
• Tracking lab test requests/results
• Identifying patients at risk
64 PRIMIS