Beyond the Screen: A Safety Investigator’s Perspective on Our Digital Future

Nick Woodier, Senior Safety Investigator at the Health Services Safety Investigations Body (HSSIB) gave us some insights into patient safety, the potential risks and benefits of digital healthcare, and the role of HSSIB.

My role, and the role of my colleagues at HSSIB, is to get to the heart of why things go wrong. We aren’t here to point fingers or assign blame. We are here to understand the systemic issues that lead to harm—or potential harm—so that we can make recommendations that improve care for everyone across England.

Lately, a large portion of our work has been focused on the digital transformation of the NHS. We’re seeing a massive shift toward Electronic Patient Records (EPRs), online consultations, and the early stages of AI integration. While these tools offer incredible potential to improve patient outcomes, my job is to look at the "sharp end" of these systems—the moments where the technology, the workflow, and the human element collide, sometimes with unintended consequences.

The Power of a "Safe Space"

HSSIB is an independent body, and our work is guided by the Health and Care Act 2022. The most critical aspect of our mandate is the "safe space" we provide.

When we investigate an incident, we rely on staff, patients, and families to share their honest thoughts and perceptions. Because we are legally required to protect that information, we can have conversations that might not happen in a standard internal Trust investigation. We then take those findings and turn them into national recommendations for bodies like the Department of Health and Social Care and the Medicines and Healthcare products Regulatory Agency (MHRA).

The Digital Paradox: Efficiency vs. Risk

I’m often asked if I’m "anti-digital" because my work focuses on where these systems fail. That couldn’t be further from the truth. I see the benefits every day. When implemented well, digital tools are a game-changer for patient safety. But the reality is that some patients are still at risk of harm because of how these systems are introduced and managed.

In our recent thematic review, we found that the biggest risks often arise during the implementation phase. A system might be brilliant, but if it’s dropped into a clinical environment without considering the local workflow, it can create new, dangerous gaps.

I remember one specific case involving an electronic prescribing system. It worked well in an adult acute setting, but when it was adapted for a paediatric setting, the configuration didn't account for the unique needs of children. A clinician was able to prescribe an incorrect dose, leading to potential harm. The staff told us, "We expected the system to stop us." And that is a common assumption—but the systems don’t always. That’s the gap we’re trying to close: ensuring that the technology supports the user, but without creating a false sense of security.

The Three Pillars of Digital Safety

If I had to boil down the most recurring issues we see in our investigations, it would come down to three main areas:

1. The Interoperability Gap This is the big one. When I talk about interoperability, I don’t just mean systems "talking" to each other. I mean the accessibility of information. Staff need the right piece of data at the right time to make a safe decision. If that information is buried in a different system, or if they don’t even know it exists, that’s a safety risk. True interoperability is about surfacing the right information at the point of care, regardless of which organisation generated it.

2. Decision Fatigue and "Note Bloat" We’re drowning in data. While more information should be better, it often leads to "note bloat," where the critical information is lost in a sea of irrelevant text. We’re seeing clinicians struggle with decision fatigue, where they’re forced to make high-stakes choices based on information that is difficult to navigate or interpret.

3. The Infrastructure Foundation This is perhaps the most frustrating issue to see. We talk about AI and cutting-edge innovation, but we’re often trying to build these tools on top of crumbling infrastructure. If you’re a community nurse with no signal, or a hospital doctor using a computer that takes ten minutes to boot up, the most advanced digital tool in the world won’t help you. If we can’t get the basics—the hardware, the Wi-Fi, the reliability—right, then everything else is going to fail. We have to stop trying to run before we can walk.

The Human Element: Co-Creation is Non-Negotiable

One of the most common things we hear from staff is that their training for new systems was disconnected from their actual reality. They were taught how to log in and where to click, but not how to use the system in the middle of a real situation.

This is why co-creation is so vital. Digital teams and users need to be in the same room from day one. If you’re designing a tool, you need to involve the people who will be using it in the most high-pressure environments. When staff are involved in the design and procurement process, the tools are more intuitive, and the risks are identified before they reach the patient.

Looking Ahead: AI and Proactive Safety

AI is the next big frontier, and it’s very much on our agenda. We’re currently exploring how we might investigate AI-related incidents. We know some of the risks: lack of transparency, the potential for bias in training data, and the "hallucinations" that large language models are prone to.

We’re also not waiting for digital incidents to happen before we start talking about them. We develop "learning prompts" in our investigations—questions for developers and healthcare organisations to ask themselves now. Things like: Have you considered how this tool fits into the existing clinical process? Have you thought about the unintended outcomes?

A Final Thought

My message to those of you working to enable digital transformation in the NHS is simple:  we need to advocate for infrastructure that works, for systems that actually talk to each other, and for a design culture that puts staff and the patient at the centre.

The digital future is full of promise, but it’s our responsibility to ensure it’s a safe future. If we can get the basics right—connectivity, accessibility, and human-centered design—we’ll be in a much stronger position to harness the next generation of healthcare innovation.

Find out more about HSSIB here: https://www.hssib.org.uk/