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Information visibility and decision support

Codes: VIS — information visibility; ALERT — decision support and alerting.

Scope

This finding concerns the step between information being stored and it becoming perceptible, interpretable and actionable in the view used for care. VIS covers availability and presentation; ALERT covers prompts, prioritisation, constraints and other decision-support behaviour. The two mechanisms often interact, but an alert is not the only way to make information usable.

What recurs in the current series

  • Important content is present but not salient. In Stephen Rhodes (representative case), a markedly abnormal result and urgent advice were filed without action; the report described first-page and colour-salience concerns alongside workload and workflow.
  • Passive record presence is not active notification. In Caliel Smith-Kwami, a time-critical newborn-screening result existed electronically but was not reliably delivered to an accountable clinician, while the paper notification was lost.
  • Availability does not ensure delivery. In Eric Thompson (representative case), an abnormal result was electronically available while efficient electronic delivery to accountable staff was absent and escalation depended on telephone communication.
  • Safety content is split between representations. In Audrey King (representative case), a paper recommendation was not surfaced in the electronic view and a suspended medicine lacked an owned review alert.
  • A warning may depend on missing computable input. In Rachelle Ross (representative case), due or outstanding screening alerts existed, but non-responder status was not automatically supplied as computable data and the additional warning depended on manual entry.
  • Decision support can be absent, incomplete or bypassable. The extracted Donald Compton, Chloe Burgess, Paula Doreen Hughes and John James reports concern, respectively, allergy checking, drug-interaction knowledge, duplicate medication and repeated refused doses.
  • Warning timing must fit the clinical task. Marian Grant concerns a VTE warning encountered at an ineffective point in the EPR workflow: repeated record access did not leave the unresolved prophylaxis risk persistently actionable. The investigation described the EPR difficulty as a root cause in the sequence, not interface design as the sole cause of death.
  • The same safety knowledge can be configured differently. Brian Bicat concerns apparently local variation in paraffin-emollient warnings across SystmOne and OptimiseRx. That digital concern was one element of a wider labelling, advice and product-information problem.
  • The view can be too broad as well as too quiet. The Jonathan Thornton report describes preset risk categories that did not communicate the target or nature of risk to the people expected to act.

These examples support a common control objective: safety-relevant information should be visible in the working context, express its source and significance, and connect to a proportionate action. They do not support a blanket rule to add more alerts.

Variation and limits

  • “Not visible” can mean absent from the receiving system, buried in a long or scanned document, displayed in an unexpected representation, or available only after an extra login. Those are different failure modes.
  • Alert design must account for specificity and burden. A respondent in the Christopher Collinson case rejected a generic confirmation alert because of alert-fatigue risk; that is respondent evidence, not a general finding that alerts are ineffective.
  • Respondents can qualify the original concern. In Ross, existing due and outstanding smear alerts narrow the issue to non-responder status rather than absence of all screening alerts.
  • Causal status varies. Some reports linked unavailable information directly to the death; others expressly treated the digital issue as a prospective risk or one component of a coupled work system.

The current review counts show repeated VIS and ALERT coding in the focused series. Because selection was targeted and the codes overlap with LOOP, HF, INT and GOV, this recurrence is not a prevalence estimate or a comparison between systems.

Defence implications — analytical translation

The following are review-derived implications for Defence Primary Healthcare and Programme CORTISONE, not requirements made by coroners:

  • make severity, required action, deadline, owner and acknowledgement visible for time-critical results;
  • expose record-source coverage and missing periods rather than presenting an incomplete view as complete;
  • test alert specificity, burden, bypass behaviour and actionability in representative deployed, remote and high-volume workflows; and
  • preserve working safety barriers during configuration, integration and capability replacement.

See the wider DPHC and Programme CORTISONE analysis.

Evidence basis: included-case dataset, coding framework, and current review counts.