Y2018-02 Information system disruptions of the Hospital District of Helsinki and Uusimaa on 7 and 8 November 2017
The data communications network of the Hospital District of Helsinki and Uusimaa (HUS) suffered a disruption at 12.15 p.m. on Tuesday, 7 November 2017. The HUS-wide disruption continued until the evening. The most serious detrimental effect of the disruption was the unavailability of the Uranus patient information system, due to which patients had to be treated with incomplete information. Other systems also suffered from disruptions. The incident affected the treatment of practically every patient and caused particular risks in the treatment of seriously ill patients. No reported treatment injuries were identified in the investigation, however.
A new disruption affecting only the patient information system occurred at 9.13 a.m. on the next day, 8 November 2017. The disruption slowed use of the system and prevented it completely in places, with effects essentially similar to those of the previous day’s disruption. This second disruption persisted until 4.30 p.m., so its impact was felt during the busiest hours of the hospitals.
The data communications disruptions were related to the chassis switch, a vital component in the patient information system. The chassis switch was nearing the end of its service life and had been in continuous use for a long time. Software and hardware updates had been neglected. Plans had been made for replacing the hardware, but they had been postponed. Even the most vital components of health care systems are not always maintained in the manner required by their critical role.
The first symptoms of the disruption had manifested two weeks earlier, when the redundancy of the data connection had probably been neglected after a routing problem. One disruption followed another, and the effects continued for several days. Disruptions make the system prone to further failures, so the data administration, user organisations and preparedness organisations must increase their readiness after them.
Short information system disruptions occur in health care from time to time, but in this case, the situation persisted. Not all hospitals and wards had made appropriate preparations for protracted information system failures. In other words, there are shortcomings in continuity planning and the procedures for executing the plans. The instructions and support for planning and drills are insufficient. There are no systematic practices for learning from the organisation's own serious disruptions or those of others in the health care sector.
Recommendations of the Safety Investigation Authority
• The Ministry of Social Affairs and Health should instruct the hospital districts in defining the criticality of the most vital information systems and their components from the perspective of patient safety. The reliability of systems classified as most critical should be ensured through, for example, redundancy, planned temporary solutions, spare parts, special components and active monitoring and maintenance measures. This matter must also be addressed in future health care reforms.
• The Ministry of Social Affairs and Health should ensure that health care operators have maintenance, update and replacement programmes in place for information systems and their components, and that the programmes are followed and supervised. A monitoring system for update needs must be put in place. The decision-making process on maintenance needs must be clarified to avoid delays.
• The Ministry of Social Affairs and Health should ensure that wards with particular patient safety risks have continuity plans in place, information systems have been taken into account in the plans, the measures, instructions and purchases required by the plans have been carried out and the implementation of the plans is practised regularly. Sufficient supervision of preparedness must be ensured in future health care reforms.
• The Ministry of Social Affairs and Health should oversee the development of a data collection and sharing system for the health care sector, with the purpose of collecting the relevant information on all incidents that cause serious risks to patient safety and formulating and publishing the relevant conclusions on improving safety for the benefit of the whole sector.