Two patients undertook radiological diagnostic examinations in Quality HealthCare Diagnostic & Imaging Centre (Jordan) through the public-private partnership programme on the same day in December last year.
It was until July 20 this year that the Hospital Authority (HA) received a report from Pok Oi Hospital regarding an incorrect radiological investigation report when a doctor retrieved a patient's clinical information from the ePR system.
Investigation showed that under the Radiological Image Sharing Pilot Project, investigation reports of the two affected patients were assigned the same file number by the Centre, and were subsequently compiled in the electronic files with patient details and then submitted to the HA through the electronic platform for uploading to the ePR system.
Preliminary findings showed that the information system of the Centre would restart the non-identification purpose file serial number of the investigation reports once the system was reset. Due to the difference of both parties' information systems, in the HA ePR system, when extracting and filing the patient's investigation reports originating from the electronic file, the report uploaded later would replace the existing report with the same file serial number automatically in the system. This led to the incorrect report being filed in the first patient's ePR.
To ensure patient safety, the doctor has further reviewed and reconfirmed that the first patient's clinical records including the radiological image and other investigation reports in the ePR were appropriate. The patient concerned has received suitable treatment. The HA has also rectified the radiological investigation report filed in the patient's medical record to ensure that future clinical management will not be affected.
Apart from assuring the patient's safety, the HA has also communicated closely with Quality HealthCare, and performed screening of all radiological investigation reports in the electronic files returned by the Centre in the past.
Six additional reports were identified with the same confusion from 2012 till July 2017. Subsequent review by the HA showed that the clinical management of patients was appropriate. The HA has already engaged Quality HealthCare to understand the related information systems of both parties. Quality HealthCare provided the respective report files to rectify the records in the HA ePR system. In addition, enhancement has already been performed by the Quality HealthCare on July 31 to strengthen the compatibility of both information systems.
The HA has just completed the review of the reports generated by the remaining 30 private service providers under the Radiological Image Sharing Pilot Project and no similar issue was found. The HA is now conducting a comprehensive review on the ePR system and the relevant electronic platforms for possible enhancements to prevent the recurrence of similar incidents. MIMS
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Difference in information systems between Hospital Authority and Quality HealthCare leads to incorrect filing of radiological investigation reports
Hayes Chu, 18 Aug 2017