Source · HSSIB Patient Safety Investigation

Electronic patient record (EPR) systems – thematic review

Published 27 November 2025 Published

NHS staff Communication and decision making Medical devices

We have completed a thematic review of 50 HSSIB reports to identify specific patient safety issues and learning related to electronic patient record (EPR) systems. The report includes a safety observation and local-level learning prompts around safe selection and procurement, implementation and ongoing optimisation of EPR systems.

View on HSSIB ↗ · Download Report PDF ↗

Summary

1 observation 13 learning prompts

Safety Observations

1 total

Observation 1 Observation National bodies responsible for providing digital advice and guidance to NHS organisations can improve patient safety by clarifying consistent definitions for design-related IT terms – such as usability and functionality – and sharing guidance on how to apply design principles to electronic patient record system configuration and optimisation.

Learning Prompts

13 total

Prompt 1 Learning prompt How does your organisation identify requirements for an EPR system to account for organisational and user (patients and staff) needs?

Prompt 2 Learning prompt How does your organisation identify whether an EPR system can perform the tasks needed to meet organisational requirements and meet expected national standards?

Prompt 3 Learning prompt How does your organisation identify whether an EPR system meets relevant standards, such as those that support clinical risk management and interoperability?

Prompt 4 Learning prompt How does your organisation ensure relevant information is requested from manufacturers and scrutinised during the selection and procurement of systems?

Prompt 5 Learning prompt Does your organisation understand the expectations for clinical risk management of health IT systems in relation to deployment, ensuring these are met and regularly reviewed?

Prompt 6 Learning prompt How does your organisation ensure representative user engagement and involvement in all aspects of the configuration, integration and ongoing optimisation of EPR systems?

Prompt 7 Learning prompt Does your organisation have a process for carrying out effective equality impact assessments to consider the needs of specific patient and staff groups who may be users of the EPR system?

Prompt 8 Learning prompt How does your organisation manage and oversee configuration changes to EPR systems to ensure they are appropriate, safe and successful?

Prompt 9 Learning prompt How does your organisation evaluate whether all necessary elements are in place before an EPR system is implemented or changed, for example through assessment of IT infrastructure and training?

Prompt 10 Learning prompt How does your organisation proactively identify new and emerging risks associated with an EPR system, and ensure these are reviewed and mitigated as far as is practicable?

Prompt 11 Learning prompt Does your organisation have routes for staff to raise concerns about the EPR system they use, with feedback to inform staff of actions taken in response?

Prompt 12 Learning prompt Does your organisation have contingency plans and processes to maintain patient safety when there are EPR system problems, and are they shared with staff?

Prompt 13 Learning prompt How does your organisation share learning from the implementation and ongoing optimisation of EPR systems to support other organisations?