TPP LTD
Other
Action Taken
TPP updated the SystmOne software to ensure the scroll bar resets to the top of the page when reviewing pathology results, preventing missed abnormal results. They also recommend clinicians use a specific view (Figure 3) to highlight trends in blood results. (AI summary)
View full response
Dear Ms Huntbach
Re: Regulation 28 report – Jade Paula Revell
Thank you for your letter of 23rd March 2023. I have previously been a fulltime NHS GP, and for the last 19 years been the clinical director and principal clinical safety officer for TPP, a company based in Leeds that supplies the SystmOne product for use by GP surgeries. The product has been in continuous usage for 24 years. There is only one version of SystmOne.
On 14th September 2022 TPP were contacted by who provided details about this sad and tragic incident. Helpfully he was able to demonstrate to our helpdesk what had happened. I was able to speak to on 15th September 2022. I will address the issues he raised with the use of screenshots from SystmOne, using fictitious data.
As a result of our conversation we were able to identify a change to be made in the system and this was released to all our users on the evening of 13th October 2022.
If the document does not adequately answer your concerns I would be happy to demonstrate the features on a Teams (or equivalent) call.
From our discussion with it appears that the GP had missed an abnormal potassium result when reviewing the results within the patient record. I use the expression ‘within the patient record’ as a pathology result first appears in the ‘Pathology Inbox’ and is processed from that screen. This is where the abnormality is first highlighted. Figure 1 below shows an example of the Pathology Inbox screen. The abnormal potassium result would have made the whole line that included Jade’s name to appear in red, showing that there was an abnormality to be reviewed. A user would have opened this result (example Figure 2) which shows how the results are individually flagged as normal or abnormal. The user would then file the result which includes the opportunity to flag the result as normal / abnormal / etc. This process would have to occur before the result would be available within the record for review.
Figure 1
Figure 2
Once the result has been filed there are two ways to review the result in SystmOne. was able to show me that one of the methods had created the opportunity for a busy GP to miss the abnormal result.
Figure 3 shows the table layout for reviewing results – where abnormal results are highlighted. There is no issue with this screen.
Figure 4 shows the full Pathology and Radiology inbox view that the GP used. Scroll bars are present in the system (contrary to what is detailed in the Regulation 28 Report) whenever the full information cannot be displayed in one screen. The behaviour that highlighted was that if the GP clicked on one result (in the middle column) and used the scroll bar in the right column to look at results not visible, the scroll bar did not automatically reset to the top, if the next result was
then selected. A very busy GP might then miss an item at the top if the scroll bar position was at the bottom of the page.
Figure 3 Figure 4
The change to ensure that the scroll bar reset to the top of the page was made and released to all our users 4 weeks later.
Conclusion I am grateful to for contacting us directly so that we could take appropriate action in a timely manner.
In general I would expect abnormal results such as this to be acted upon at the pathology filing stage, and we recommend that clinicians use the view in figure 3 (rather than figure 4) to highlight the trends in blood results.
Please let me know if you have further concerns.
Re: Regulation 28 report – Jade Paula Revell
Thank you for your letter of 23rd March 2023. I have previously been a fulltime NHS GP, and for the last 19 years been the clinical director and principal clinical safety officer for TPP, a company based in Leeds that supplies the SystmOne product for use by GP surgeries. The product has been in continuous usage for 24 years. There is only one version of SystmOne.
On 14th September 2022 TPP were contacted by who provided details about this sad and tragic incident. Helpfully he was able to demonstrate to our helpdesk what had happened. I was able to speak to on 15th September 2022. I will address the issues he raised with the use of screenshots from SystmOne, using fictitious data.
As a result of our conversation we were able to identify a change to be made in the system and this was released to all our users on the evening of 13th October 2022.
If the document does not adequately answer your concerns I would be happy to demonstrate the features on a Teams (or equivalent) call.
From our discussion with it appears that the GP had missed an abnormal potassium result when reviewing the results within the patient record. I use the expression ‘within the patient record’ as a pathology result first appears in the ‘Pathology Inbox’ and is processed from that screen. This is where the abnormality is first highlighted. Figure 1 below shows an example of the Pathology Inbox screen. The abnormal potassium result would have made the whole line that included Jade’s name to appear in red, showing that there was an abnormality to be reviewed. A user would have opened this result (example Figure 2) which shows how the results are individually flagged as normal or abnormal. The user would then file the result which includes the opportunity to flag the result as normal / abnormal / etc. This process would have to occur before the result would be available within the record for review.
Figure 1
Figure 2
Once the result has been filed there are two ways to review the result in SystmOne. was able to show me that one of the methods had created the opportunity for a busy GP to miss the abnormal result.
Figure 3 shows the table layout for reviewing results – where abnormal results are highlighted. There is no issue with this screen.
Figure 4 shows the full Pathology and Radiology inbox view that the GP used. Scroll bars are present in the system (contrary to what is detailed in the Regulation 28 Report) whenever the full information cannot be displayed in one screen. The behaviour that highlighted was that if the GP clicked on one result (in the middle column) and used the scroll bar in the right column to look at results not visible, the scroll bar did not automatically reset to the top, if the next result was
then selected. A very busy GP might then miss an item at the top if the scroll bar position was at the bottom of the page.
Figure 3 Figure 4
The change to ensure that the scroll bar reset to the top of the page was made and released to all our users 4 weeks later.
Conclusion I am grateful to for contacting us directly so that we could take appropriate action in a timely manner.
In general I would expect abnormal results such as this to be acted upon at the pathology filing stage, and we recommend that clinicians use the view in figure 3 (rather than figure 4) to highlight the trends in blood results.
Please let me know if you have further concerns.