Article Text

How reliable are clinical systems in the UK NHS? A study of seven NHS organisations
  1. Susan Burnett1,
  2. Bryony Dean Franklin2,
  3. Krishna Moorthy3,
  4. Matthew W Cooke4,
  5. Charles Vincent5
  1. 1Centre for Patient Safety and Service Quality (CPSSQ), Division of Surgery and Cancer, Department of Surgery, Faculty of Medicine, Imperial College London, London, UK
  2. 2Centre for Medication Safety and Service Quality, UCL School of Pharmacy and Imperial College Healthcare NHS Trust, London, UK
  3. 3Upper Gastrointestinal Surgery, Division of Surgery and Cancer, Department of Biosurgery and Surgical Technology, Imperial College London, London, UK
  4. 4Warwick Medical School, Heart of England NHS Foundation Trust, Coventry, UK
  5. 5Centre for Patient Safety and Service Quality (CPSSQ), Division of Surgery and Cancer, Department of Surgery, Imperial College London, London, UK
  1. Correspondence to Susan Burnett, Centre for Patient Safety and Service Quality, Imperial College London, Faculty of Medicine, Room 508 Medical School Building, St Mary's Campus, Norfolk Place, London W2 1PG, UK; s.burnett{at}


Background It is well known that many healthcare systems have poor reliability; however, the size and pervasiveness of this problem and its impact has not been systematically established in the UK. The authors studied four clinical systems: clinical information in surgical outpatient clinics, prescribing for hospital inpatients, equipment in theatres, and insertion of peripheral intravenous lines. The aim was to describe the nature, extent and variation in reliability of these four systems in a sample of UK hospitals, and to explore the reasons for poor reliability.

Methods Seven UK hospital organisations were involved; each system was studied in three of these. The authors took delivery of the systems' intended outputs to be a proxy for the reliability of the system as a whole. For example, for clinical information, 100% reliability was defined as all patients having an agreed list of clinical information available when needed during their appointment. Systems factors were explored using semi-structured interviews with key informants. Common themes across the systems were identified.

Results Overall reliability was found to be between 81% and 87% for the systems studied, with significant variation between organisations for some systems: clinical information in outpatient clinics ranged from 73% to 96%; prescribing for hospital inpatients 82–88%; equipment availability in theatres 63–88%; and availability of equipment for insertion of peripheral intravenous lines 80–88%. One in five reliability failures were associated with perceived threats to patient safety. Common factors causing poor reliability included lack of feedback, lack of standardisation, and issues such as access to information out of working hours.

Conclusions Reported reliability was low for the four systems studied, with some common factors behind each. However, this hides significant variation between organisations for some processes, suggesting that some organisations have managed to create more reliable systems. Standardisation of processes would be expected to have significant benefit.

  • Clinical systems
  • reliability
  • patient safety
  • accreditation
  • health policy
  • healthcare quality improvement
  • quality improvement
  • medication error
  • medication
  • medical error
  • medication safety
  • continuous quality improvement
  • emergency department
  • prehospital care
  • safety culture
  • root cause analysis
  • risk management

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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  • Funding The study was commissioned and funded by the Health Foundation (Registered Charity Number 286967) as part of their work to examine systems reliability in healthcare and its effects on patient safety. The Centre for Patient Safety and Service Quality is supported by the UK National Institute of Health Research. The researchers are independent from the funders.

  • Competing interests All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare that (1) all authors have support from The Health Foundation for the submitted work; (2) all authors have no relationships with The Health Foundation that might have an interest in the submitted work in the previous 3 years; (3) their spouses, partners, or children have no financial relationships that may be relevant to the submitted work; and (4) none of the authors have non-financial interests that may be relevant to the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The full research report is available on the Health Foundation web site. Further information can be obtained from the authors.