FHIR004
Unclear headings
Initial Risk Rating
| Likelihood |
Consequence |
Risk |
| Medium |
Major |
3 |
Residual Hazard Risk Rating
| Likelihood |
Consequence |
Risk |
| Very Low |
Major |
2 |
Hazard Description
Inconsistent use of (too many, unclear) headings which might not be supported by some systems.
Potential Clinical Impact
- Inconsistencies in clinical data transfer between systems.
- Incorrect data transfer - data are presented under an inappropriate heading, resulting in being missed or misinterpreted by the clinicians.
- Critical clinical information may be omitted, which can cause an adverse effect on patient safety.
- Incorrect information entered under an inappropriate heading, leading to inappropriate treatment.
Possible Causes
- Incorrect data entry as it is unclear what heading information should be recorded against, due to poor understanding of headings.
- The headings are grouped in a way that might not work for a speciality / service / clinician.
- Too many headings will be time-consuming and burdensome, which may result in omission of key clinical information.
- The names and definitions of headings do not match between different systems.
- Clinicians unable to add information because the headings are not in their systems.
- No national agreement on the use of some elements e.g. confidentiality, and therefore the use of these are not recommended in the UK.
Existing Controls
Use of current headings available in current local or national system such as SCRa.
Design
- Systems' implementers to consider heading and field definitions to capture critical data.
- Implementers have to ensure they have the most up-to-date version of the headings, and that the headings are correctly implemented in their systems.
- Clear definitions of the information content under each heading, avoiding overlap.
Test
Appropriate testing's to ensure that the system can support all defined headings.
Training
Training materials to consider users to be trained to use headings appropriately, and to complete only fields that are relevant to individual patient/specialty.
Business Process Change
IT systems will be required to support all the headings, however, not all headings will be mandatory for implementers. Local agreements should determine the optional headings to be used by a particular system which must match those in the record standard.
