Enhancing Patient Safety Event Reporting. A Systematic Review of System Design Features

Patient Safety Incidents in Operating Rooms Reported in the Past Five Years (2017-2021) in Korea

Purpose

Patient safety incidents in the operating room require special attention because they can cause catastrophic and irreversible conditions in patients. Although patient safety incidents have different characteristics, there may be similarities and patterns of risk factors that may be common. Therefore, this study analyzed factors associated with the PSIs by analyzing data from the Korean Patient Safety Reports from 2017 to 2019.

Methods

The "Patient Safety Incidents Data from 2017 to 2021" systematically collected by the Korea Institute for Healthcare Accreditation, include patient safety incident reports from medical institutions. Data on 1140 patient safety incidents in the operating room were analyzed. They included patients' gender and age, Hospital size, Incident seasons, incident time, Incident reporter, incident type, Medical department, and Incident severity. The Incident severity was analyzed by dividing it into three stages: near miss, adverse event, sentinel event, which are applied by domestic medical institutions.

Results

The highest number of OR patient safety incidents were related to surgery and anesthesia. On analyzing the probability of adverse events based on near misses, the significant variables were patient gender, incident reporter, incident type, and Medical department. Additionally, the factors that were likely to precipitate sentinel events based on near misses were patient gender, incident time, reporter, and incident type.

Conclusion

To prevent sentinel events in Patient safety incidents, female and during night shifts are required to pay close attention. Moreover, it is necessary to establish a patient safety reporting system in which not only all medical personnel, but also patients, generally, can actively participate in patient safety activities.

Developing, Implementing, Evaluating Electronic Apparent Cause Analysis Across a Health Care System

An interdisciplinary team developed, implemented, and evaluated a standardized structure and process for an electronic apparent cause analysis (eACA) tool that includes principles of high reliability, human factors engineering, and Just Culture. Steps include assembling a team, describing what happened, determining why the event happened, determining how defects might be fixed, and deciding which defects will be fixed. The eACA is an intuitive tool for identifying defects, apparent causes of those defects, and the strongest corrective actions. Moreover, the eACA facilitates system learning by aggregating apparent causes and corrective action trends to prioritize and implement system change(s).

Assessing the impact of an electronic chemotherapy order verification checklist on pharmacist reported errors in oncology infusion centers of a health-system

PURPOSE

Chemotherapies are medications with narrow therapeutic indices and potential for severe adverse events that account for at least 1 to 3% of medication errors in all adult and pediatric oncology patients. The use of an electronic chemotherapy order verification (ECOV) checklist can standardize the steps of chemotherapy verification by pharmacists, which can potentially increase medication error detection at the point of dispensing. This study evaluated the implementation of a standardized chemotherapy order verification checklist on pharmacist error reporting, particularly good-catches or near-misses type errors.

METHODS

This retrospective, quasi-experimental, pre-/post-analysis of internal voluntary medication errors reported from 12 University Hospitals Seidman oncology infusion centers from June 2022 through December 2022. Error reports, categorized based on severity, were compared pre/post-implementation of the ECOV checklist.

RESULTS

A total of 62 and 71 cases of medication errors were reported in the pre-intervention and post-intervention periods, respectively. The rate of pharmacy reported medication errors was 2.4 times greater in the post-intervention period of the ECOV checklist (p < 0.006). Pharmacy reported errors increased among all error severities reported. However, the finding did not deduce a statistically significant difference (p < 0.244).

CONCLUSION

This study demonstrates the effectiveness of implementing the ECOV checklist in increasing the rate of pharmacy reported medication errors. The checklist was designed to complement existing pharmacist workflow and provide a source of documentation for steps of sequential pharmacist evaluation.

A qualitative study of the reasons for low patient safety incident reporting among Indonesian nurses

OBJECTIVES

to investigate the reasons for low patient safety incident reporting among Indonesian nurses.

METHODS

this qualitative case study was conducted among 15 clinical nurses selected purposively from a public hospital in Lampung, Indonesia. Interview guidelines were used for data collection through face-to-face in-depth interviews in July 2022. The thematic approach was used to analyze the data.

RESULTS

in this present study, seven themes emerged (1) Understanding incident reporting; (2) The culture; (3) Consequences of reporting; (4) Socialization and training; (5) Facilities; (6) Feedback; and (7) Rewards and punishments.

FINAL CONSIDERATIONS

these findings should be considered challenges for the patient safety committee and hospital management to increase patient safety incident reporting, particularly among nurses in the hospital.

Characterization of Safety Events Involving Technology in Primary and Community Care

BACKGROUND

The adoption of technology in health care settings is often touted as an opportunity to improve patient safety. While some adverse events can be reduced by health information technologies, technology has also been implicated in or attributed to safety events. To date, most studies on this topic have focused on acute care settings.

OBJECTIVES

To describe voluntarily reported safety events that involved health information technology in community and primary care settings in a large Canadian health care organization.

METHODS

Two years of safety events involving health information technology (2016-2018) were extracted from an online voluntary safety event reporting system. Events from primary and community care settings were categorized according to clinical setting, type of event, and level of harm. The Sittig and Singh sociotechnical system model was then used to identify the most prominent sociotechnical dimensions of each event.

RESULTS

Of 104 reported events, most (n = 85, 82%) indicated the event resulted in no harm. Public health had the highest number of reports (n = 45, 43%), whereas home health had the fewest (n = 7, 7%). Of the 182 sociotechnical concepts identified, many events (n = 61, 59%) mapped to more than one dimension. Personnel (n = 48, 46%), Workflow and Communication (n = 37, 36%), and Content (n = 30, 29%) were the most common. Personnel and Content together was the most common combination of dimensions.

CONCLUSION

Most reported events featured both technical and social dimensions, suggesting that the nature of these events is multifaceted. Leveraging existing safety event reporting systems to screen for safety events involving health information technology, and applying a sociotechnical analytic framework can aid health organizations in identifying, responding to, and learning from reported events.

Using Community Detection Techniques to Identify Themes in COVID-19-Related Patient Safety Event Reports

OBJECTIVES

The COVID-19 pandemic has transformed how healthcare is delivered to patients. As the pandemic progresses and healthcare systems continue to adapt, it is important to understand how these changes in care have changed patient care. This study aims to use community detection techniques to identify and facilitate analysis of themes in patient safety event (PSE) reports to better understand COVID-19 pandemic's impact on patient safety. With this approach, we also seek to understand how community detection techniques can be used to better identify themes and extract information from PSE reports.

METHODS

We used community detection techniques to group 2082 PSE reports from January 1, 2020, to January 31, 2021, that mentioned COVID-19 into 65 communities. We then grouped these communities into 8 clinically relevant themes for analysis.

RESULTS

We found the COVID-19 pandemic is associated with the following clinically relevant themes: (1) errors due to new and unknown COVID-19 protocols/workflows; (2) COVID-19 patients developing pressure ulcers; (3) unsuccessful/incomplete COVID-19 testing; (4) inadequate isolation of COVID-19 patients; (5) inappropriate/inadequate care for COVID-19 patients; (6) COVID-19 patient falls; (7) delays or errors communicating COVID-19 test results; and (8) COVID-19 patients developing venous thromboembolism.

CONCLUSIONS

Our study begins the long process of understanding new challenges created by the pandemic and highlights how machine learning methods can be used to understand these and similar challenges. Using community detection techniques to analyze PSE reports and identify themes within them can help give healthcare systems the necessary information to improve patient safety and the quality of care they deliver.

Role of patient safety attitudes between career identity and turnover intentions of new nurses in China: A cross-sectional study

Background

Patient safety is a key priority for healthcare systems, which is not only about the safety and quality development of health care but also about the safety of patients' lives. However, there has been little research exploring the relationship between new nurses' willingness to leave, patient safety culture, and professional identity. This study was to explore patient safety for new nurses, examine the relationship between professional identity, patient safety culture, and turnover intentions of newly recruited nurses in China, and validate the mediating role of patient safety culture.

Methods

From August 2019 to September 2021, we collected data from newly recruited nurses in 5 large tertiary public hospitals in Anhui Province, China using a questionnaire survey. Descriptive analysis, a univariate analysis, Pearson correlation analysis, and mediated regression analysis were used to estimate the current status of patient safety attitudes and the effect of safety culture on career identity and turnover intentions among newly recruited nurses.

Results

The turnover intention of 816 newly recruited nurses was 14.16 ± 3.14%. Patient safety culture was positively associated with career identity (r = 0.516, P < 0.01) and negatively associated with turnover intentions (r = -0.437, P < 0.01), while patient safety was also a partial mediator between career identity and turnover intentions.

Conclusions

The results showed that the low patient safety attitudes of new nurses in China should not be ignored. The impact of professional identity on patient safety has important practical implications for promoting a culture of safety among new nurses and reducing turnover rates.

Change in the Number of Patient Safety Reports Through a 16-Year Patient Safety Initiative: A Retrospective Study Focusing on the Incident Severity and Type in a Japanese Hospital

Purpose

To describe the long-term quantitative change in the number of submissions of patient safety reports after the introduction of a patient safety reporting system, focusing on incident severity and type.

Patients and Methods

This study was performed at a tertiary care hospital in Japan. Patient safety reports from 2006 to 2020 were retrospectively reviewed. Incident severity was classified from level 0 (near miss) to level 5 (fatality). The incident types included those related to medication, patient care, drains and catheters, procedures and interventions, examinations, medical devices, and blood transfusions. The study period was divided into 1. 2004–2007; 2. 2008–2014; and 3. 2015–2020 based on the implementation of hospital patient safety strategies. The number of reports per hospital worker was compared among the study periods and the incident levels and types.

Results

We analyzed 96,332 reports extracted from the patient safety reporting system of the hospital. The total number of reports per hospital worker has increased over time. The numbers of levels 0 and 1 incidents increased throughout the study period. In addition, levels 3a and 3b incidents increased between periods 2 and 3. All incident types, except for procedure and intervention-related incidents, increased between periods 1 and 2 and between periods 1 and 3. The number of procedure and intervention-related incidents increased between periods 2 and 3, although it did not between periods 1 and 2.

Conclusion

We found increases in the number of patient safety reports according to the incident severity and type. This suggests two contextual changes occurring during the cultural maturity process, which reflected the development of organizational patient safety culture in our institution. The first was the establishment of a reporting attitude in the institution. The second was to overcome barriers to patient safety.

Electronic surveillance of patient safety events using natural language processing

Objective

We describe our approach to surveillance of reportable safety events captured in hospital data including free-text clinical notes. We hypothesize that a) some patient safety events are documented only in the clinical notes and not in any other accessible source; and b) large-scale abstraction of event data from clinical notes is feasible.

Materials and Methods

We use regular expressions to generate a training data set for a machine learning model and apply this model to the full set of clinical notes and conduct further review to identify safety events of interest. We demonstrate this approach on peripheral intravenous (PIV) infiltrations and extravasations (PIVIEs).

Results

During Phase 1, we collected 21,362 clinical notes, of which 2342 were reviewed. We identified 125 PIV events, of which 44 cases (35%) were not captured by other patient safety systems. During Phase 2, we collected 60,735 clinical notes and identified 440 infiltrate events. Our classifier demonstrated accuracy above 90%.

Conclusion

Our method to identify safety events from the free text of clinical documentation offers a feasible and scalable approach to enhance existing patient safety systems. Expert reviewers, using a machine learning model, can conduct routine surveillance of patient safety events.

Developing a Prospective Incident-Reporting System for Clinical Perfusion Practice in the United States

For nearly 20 years, prominent perfusionists have called for a perfusion-centric prospective incident-reporting system to collect near-miss and patient harm incidents that occur during clinical practice in the United States. In this article, we describe the development of a widely available prospective incident-reporting system for use by perfusionists in the United States. The system was developed in three phases: literature review, system incorporation, and submission for listing as a Patient Safety Organization (PSO). It is anticipated that the knowledge gained from analysis of events contributed to this PSO-protected reporting system will lead to improvements in safety and quality of perfusion services, as well as expanding the understanding of best practices in training, equipment use, system design, and simulation scenarios.

Accident & Emergency Informatics and One Digital Health

OBJECTIVES

Climate changes are the major challenge in public and individual health, as they modify the ecosystem and yield contagious diseases from animal to human. Furthermore, we notice the rapid development of elderly, changing the population demographic. These critical measures have imposed economical costs, require trained personnel, and reduce the healthcare systems' performances.

METHODS

COVID-19 pandemic showed that digital health paradigms such as m-health, telemedicine, and Internet of medical things (IoMT) should be further developed for such disasters. Quarantine was experienced frequently at different levels, which indicates the urgent need to develop smart medical homes for continuous monitoring of the patients. Human health, environment, and animals are the three interwoven aspects of public health that should be formulated under a conceptual and unified framework. Accident and Emergency Informatics (A&EI) considers the prediction and prevention of an individual's health in the long term and detects instant accidents and emergencies for further processes linking to hospital and rescue services for lowering the impact. One Digital Health (ODH) considers the health of the human, the animal, and the environment as a whole.

RESULTS & CONCLUSION

In this position paper, we discuss the mutual benefits of A&EI and ODH in disaster management. We outline the mission, current status of A&EI in healthcare, and summarize the most important development of A&EI-related scope in the other fields of science. We discuss developing smart environments to monitor environmental and animal aspects. Then we examine the use of the ODH framework for enhancing the A&EI capacities to deal with complex disasters. Moreover, we discuss the further development of the international standard accident number (ISAN) to include and link environmental and animal event related data. Besides, ODH will cope with the A&EI protocols and technical specifications to be part of A&EI in the application layer.

Patient safety and leadership style in the government general hospitals in Kuwait: a multi-method study

Purpose

This study aims to evaluate the relationships between leadership style and reported incidents, reporting practices and patient safety initiatives in Kuwaiti hospitals.

Design/methodology/approach

This cross-sectional and retrospective quantitative multi-centre study was conducted in a secondary care setting. The multifactor leadership questionnaire and the patient safety questionnaire were distributed in six general hospitals to a sample of physicians, nurses and pharmacists. Incident reports were reviewed in each hospital to assess reporting practices.

Findings

The hospital with the most safety incident reports scored the highest on good reporting practices, whereas the hospital with the lowest score of poor reporting practices had reported fewer incidents. Reporting was better if an error reached the patient but caused no harm. Overall, reporting practices and implementation of patient safety initiatives in the hospitals were suboptimal. Nevertheless, a transformational leadership style had a positive effect on patient safety and reporting practices.

Practical implications

This study represents a baseline for researchers to assess the relationship between leadership style and patient safety. Moreover, it highlights significant considerations to be addressed when planning patient safety improvement programmes. More investment is needed to understand how to raise transformational leaders who are more effective on patient safety. Further studies that include primary and tertiary health-care settings and the private sector are required.

Originality/value

To the best of the authors’ knowledge, this study is the first in Kuwait to report on the relationship between transformational leadership and safety practices.

Use of a Rubric to Improve the Quality of Internal Medicine Resident Event Reporting

INTRODUCTION

As frontline providers, residents report patient safety events and provide crucial safety feedback. Specific ACGME and AAMC requirements for graduating residents include active participation in event reporting and patient safety investigations. However, formal training on what information a quality event report should include to effect real change in the health care system is lacking.

METHODS

This practical, interactive, case-based workshop educates residents on the key components of a quality event report in a 1-hour time frame. The scoring rubric offers quantitative feedback on the quality of information provided in residents' own event reports. The materials include a presentation template, sample teaching points, pre- and posttraining patient safety cases for residents to complete their own event reports about, and a standardized rubric to score event reports for feedback.

RESULTS

During the fall of 2019, 198 internal medicine residents completed the workshop, and 143 matched pre- and postcourse surveys were reviewed. Residents' ability to correctly identify the key concepts of an event report improved from a median score of 4 to 8 (p < .001). After completion of training, residents reported increased knowledge regarding the content of an effective event report (p < .001) and increased confidence in their ability to write one (p < .001).

DISCUSSION

Residents' knowledge of key event-reporting concepts and confidence in reporting improved after completion of the workshop. This brief interactive training and its novel rubric can be used as a standardized tool for patient safety curricula in academic training programs.

Implementing the Clinical Occurrence Reporting and Learning System: A Double-Loop Learning Incident Reporting System in Long-term Care

BACKGROUND

Most incident reporting systems have been questioned for their effectiveness in improving patient safety as they serve as an administrative reporting system.

LOCAL PROBLEM

The long-term-care sector faced unique challenges, such an aging population and resource constraints, and its current incident reporting systems lack contextualization to address its needs.

METHODS

This quality improvement project was conducted at a 624-bed nursing home in Singapore from January to September 2019, using the Plan-Do-Study-Act methodology.

INTERVENTION

The existing incident reporting system (known as Clinical Occurrence Reporting and Learning System-CORALS) was redesigned to facilitate double-loop learning and workplace improvement initiatives.

RESULTS

The results demonstrated significant improvement in nurses' postintervention knowledge and confidence in handling future adverse events and greater staff awareness and information dissemination on patient safety issues.

CONCLUSION

A double-looped system could improve nurses' patient safety awareness and their workplace practices, which would ultimately lead to better patient outcomes.

Feeling better on hemodialysis: user-centered design requirements for promoting patient involvement in the prevention of treatment complications

OBJECTIVE

Hemodialysis patients frequently experience dialysis therapy sessions complicated by intradialytic hypotension (IDH), a major patient safety concern. We investigate user-centered design requirements for a theory-informed, peer mentoring-based, informatics intervention to activate patients toward IDH prevention.

METHODS

We conducted observations (156 hours) and interviews (n = 28) with patients in 3 hemodialysis clinics, followed by 9 focus groups (including participatory design activities) with patients (n = 17). Inductive and deductive analyses resulted in themes and design principles linked to constructs from social, cognitive, and self-determination theories.

RESULTS

Hemodialysis patients want an informatics intervention for IDH prevention that collapses distance between patients, peers, and family; harnesses patients' strength of character and resolve in all parts of their life; respects and supports patients' individual needs, preferences, and choices; and links "feeling better on dialysis" to becoming more involved in IDH prevention. Related design principles included designing for: depth of interpersonal connections; positivity; individual choice and initiative; and comprehension of connections and possible actions.

DISCUSSION

Findings advance the design of informatics interventions by presenting design requirements for outpatient safety and addressing key design opportunities for informatics to support patient involvement; these include incorporation of behavior change theories. Results also demonstrate the meaning of design choices for hemodialysis patients in the context of their experiences; this may have applicability to other populations with serious illnesses.

CONCLUSION

The resulting patient-facing informatics intervention will be evaluated in a pragmatic cluster-randomized controlled trial in 28 hemodialysis facilities in 4 US regions.

Patient safety in an endoscopy unit: an observational retrospective analysis of reported incidents

INTRODUCTION

Patient safety is a serious public health with serious implications on morbidity, mortality, and quality of life of patients, in addition to negatively affecting the public image of healthcare institutions and professionals. It requires further investigation, especially in specialties lacking published data, such as endoscopy.

OBJECTIVE

To analyze patient safety incidents reported in a gastrointestinal endoscopy unit of a tertiary hospital in southern Brazil.

METHODS

This retrospective, cross-sectional study quantitatively described patient safety incidents related to endoscopic procedures. The sample consisted of reports of incidents that occurred from 2015 to 2017. The data were descriptively analysed, and the study was approved by the relevant research ethics committee.

RESULTS

Overall, 42,863 endoscopic procedures were performed and 167 reports were submitted in the period, accounting for a prevalence of incidents of 0.38%. Most incidents did not result in unnecessary harm to patients (76.6%). The most prevalent incidents were those related to patient identification, followed by those related to pathology exams, exam reports, gastrointestinal perforations, skin lesions, falls and medication errors. The rate of adverse events (harm to patient) in patients undergoing any endoscopic procedure was 0.06%.

CONCLUSIONS

The incidence of unnecessary harm (adverse event) associated with any endoscopic procedure was relatively low in this study. However, the identification of reported incidents is crucial for evaluating and improving the quality of care provided to patients.

Interventions to improve resident reporting of patient safety events: a quality improvement initiative

Background

Patient safety events (PSE) are opportunities to improve patient care but physicians rarely report them. In a previous study, residents identified knowledge regarding what constitutes a PSE, perceived lack of time, complexity of the reporting process, lack of feedback, and perceived failure to resolve the issue despite reporting to be barriers limiting their PSE reporting. The residency programs and system patient safety and quality improvement departments created targeted interventions to address identified barriers.

Objective

Assess effectiveness of targeted interventions on improving PSE reporting rates amongst residents.

Methods

As part of a multi-residency patient safety project, interventions were created to focus on the removal of barriers to reporting PSE identified previously. Post-interventions, an identical cross-sectional survey of the residents at the same two community teaching hospitals was conducted from Sept to Dec 2018 through an online questionnaire tool.

Results

78 out of 149 residents (52.3%) completed the survey. We found a significant improvement in the number of residents who endorsed reporting a PSE in the past 1 year (51.2% vs 23.5%, p = 0.001), as well as during the course of their training (52.6% vs 26.5%, P = 0.001). There was also a significant decrease in the number of residents who were unsure of how to report a PSE (p = 0.031) as well as those who viewed medical error as a sign of incompetence (p = 0.036).

Conclusion

Our study demonstrates that simplifying the PSE reporting process, improving knowledge and acceptance of patient safety/quality improvement principles and promotion of a just culture improves resident PSE reporting.

Human-Computer Interaction, Ethics, and Biomedical Informatics

Objectives : To provide an overview of recent work at the intersection of Biomedical Informatics, Human-Computer Interaction, and Ethics.

Methods : Search terms for Human-Computer Interaction, Biomedical Informatics, and Ethics were used to identify relevant papers published between 2017 and 2019.Relevant papers were identified through multiple methods, including database searches, manual reviews of citations, recent publications, and special collections, as well as through peer recommendations. Identified articles were reviewed and organized into broad themes.

Results : We identified relevant papers at the intersection of Biomedical Informatics, Human-Computer Interactions, and Ethics in over a dozen journals. The content of these papers was organized into three broad themes: ethical issues associated with systems in use, systems design, and responsible conduct of research.

Conclusions : The results of this overview demonstrate an active interest in exploring the ethical implications of Human-Computer Interaction concerns in Biomedical Informatics. Papers emphasizing ethical concerns associated with patient-facing tools, mobile devices, social media, privacy, inclusivity, and e-consent reflect the growing prominence of these topics in biomedical informatics research. New questions in these areas will likely continue to arise with the growth of precision medicine and citizen science.

Anaesthesia and perioperative incident reporting systems: Opportunities and challenges

Incident Reporting Systems (IRS) continue to be an important influence on improving patient safety. IRS can provide valuable insights into how to prevent patients from being harmed at the organizational level. But inadequate expectations and misuse, for performance assessment, patient safety measurement or research, have hindered the full IRS potential. Health care organizations need to develop effective strategies built on trust and truth telling to improve the impact of IRS. This requires strategies to address the limited resources to analyse the near-misses or adverse events; avoid the punitive drift through maintaining the anonymity and protective legislation; integrating IRS and avoiding its confusion with mandatory adverse event response systems; training data analysts to focus on the system instead of the individual through a balanced simple taxonomy; combine the analyses at the local level, to reinforce effective and personalized feedback, with the potential of a national or supranational learning platform.

Patient Safety Incident Reporting In Indonesia: An Analysis Using World Health Organization Characteristics For Successful Reporting

Background

Incident reporting is widely acknowledged as one of the ways of improving patient safety and has been implemented in Indonesia for more than ten years. However, there was no significant increase in the number of reported incidents nationally. The study described in this paper aimed at assessing the extent to which Indonesia’s patient safety incident reporting system has adhered to the World Health Organization (WHO) characteristics for successful reporting.

Methods

We interviewed officials from 16 organizations at national, provincial and district or city levels in Indonesia. We reviewed several policies, guidelines and regulations pertinent to incident reporting in Indonesia and examined whether the WHO characteristics were covered in these documents. We used NVivo version 9 to manage the interview data and applied thematic analysis to organize our findings.

Results

Our study found that there was an increased need for a non-punitive system, confidentiality, expert-analysis and timeliness of reporting, system-orientation and responsiveness. The existing guidelines, policies and regulations in Indonesia, to a large extent, have not satisfied all the required WHO characteristics of incident reporting. Furthermore, awareness and understanding of the reporting system amongst officials at almost all levels were lacking.

Conclusion

Despite being implemented for more than a decade, Indonesia’s patient safety incident reporting system has not fully adhered to the WHO guidelines. There is a pressing need for the Indonesian Government to improve the system, by putting specific regulations and by creating a robust infrastructure at all levels to support the incident reporting.

Exploration and Initial Development of Text Classification Models to Identify Health Information Technology Usability-Related Patient Safety Event Reports

BACKGROUND

With the pervasive use of health information technology (HIT) there has been increased concern over the usability and safety of this technology. Identifying HIT usability and safety hazards, mitigating those hazards to prevent patient harm, and using this knowledge to improve future HIT systems are critical to advancing health care.

PURPOSE

The purpose of this work is to demonstrate the feasibility of a modeling approach to identify HIT usability-related patient safety events (PSEs) from the free-text of safety reports and the utility of such models for supporting patient safety analysts in their analysis of event data.

METHODS

We evaluated three feature representations (bag-of-words [BOWs], topic modeling, and document embeddings) to classify HIT usability-related PSE reports using 5,911 manually annotated reports. Model results were reviewed with patient safety analysts to gather feedback on their usefulness and integration into workflow.

RESULTS

The combination of term frequency-inverse document frequency BOWs and document embedding features modeled with support vector machine (SVM) with radial basis function (RBF) had the highest overall precision-recall area under the curve (AUC) and f1-score, 72 and 66%, respectively. Using only document embedding features achieved a similar precision-recall AUC and f1-score performance with the SVM RBF model, 70 and 66%, respectively. Models generally favored specificity and sensitivity over precision. Patient safety analysts found the model results to be useful and offered three suggestions on how it can be integrated into their workflow at the point of report entry, in a visual dashboard layer, and to support data retrievals.

CONCLUSION

Text mining and document embeddings can support identification of HIT usability-related PSE reports. The positive feedback received on the HIT usability model shows its potential utility in real-world applications.

Understanding Health Information Technology Induced Medication Safety Events by Two Conceptual Frameworks

BACKGROUND

While health information technology (health IT) is able to prevent medication errors in many ways, it may also potentially introduce new paths to errors. To understand the impact of health IT induced medication errors, this study aims to conduct a retrospective analysis of medication safety reports.

METHODS

From the U.S. Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience database, we identified reports in which health IT is a contributing factor to medication errors. We applied two conceptual frameworks, Sittig and Singh's sociotechnical model and Coiera's information value chain, to examine the identified reports.

RESULTS

We identified 152 unique reports on health IT induced medication errors as the final report set for review. The majority (65.13%) of the reports involved multiple contributing factors according to the sociotechnical model. Three dimensions, that is, clinical content, human-computer interface, and people, were involved in more reports than the others. The transition of the effects of health IT on medication practice was summarized using information value chain. Health IT related contributing factors may lead to receiving wrong information, missing information, receiving partial information and delayed information, and receiving wrong information and missing information tend to cause the commission errors in decision-making.

CONCLUSION

The two frameworks provide an opportunity to understand a comprehensive context of safety event and the impact of health IT induced errors on medication safety. The sociotechnical model helps identify the aspects causing medication safety issues. The information value chain helps uncover the effect of the health IT induced medication errors on health care process and patient outcomes.

A prototype of knowledge-based patient safety event reporting and learning system

Background

Patient falls, the most common safety events resulting in adverse patient outcomes, impose significant costs and have become a great burden to the healthcare community. Current patient fall reporting systems remain in the early stage that is far away from reaching the ultimate goal toward a safer healthcare. According to the Kirkpatrick model, the key challenge in reaction, learning, behavior and results is the realization of learning stage due to the lack of knowledge management, sharing and growing mechanism.

Methods

Based on the key contributing factors defined by AHRQ Common Formats 2.0, a hierarchical list of contributing factors for patient falls was established by expert review and discussion. Using the list as an infrastructure, we designed and developed a novel reporting system, where a strategy to identify contributing factors is intended to provide reporters knowledge support, in the form of similar cases and potential solutions. A survey containing two scenarios was conducted to evaluate the learning effect of our system.

Results

In both scenarios, potential solutions recommended by the system were annotated with correct contributing factors, and presented only when the corresponding factors were identified from the query report or selected by the user. The five experts show substantial consistency (Fleiss’ kappa > 0.6) and high agreement (ranging between fully agree and mostly agree) in the assessment of the three perspectives of the system, which verifies the effectiveness of the proposed knowledge support toward sharing and learning through the novel reporting system.

Conclusions

This study proposed a profile of contributing factors that could measure the similarity of patient safety events. Based on the profile, a knowledge-based reporting and learning system was developed to bridge the gap between surveillance, reporting, and retrospective analysis in the fall management circle. The system holds promise in improving event reporting toward better and safer healthcare.

Toward Reporting Support and Quality Assessment for Learning from Reporting: A Necessary Data Elements Model for Narrative Medication Error Reports

To understand and prevent medication errors, spontaneous reporting systems are developed and implemented to aggregate medication error reports for root cause analysis (RCA). Despite of the rich relational information in medication error reports, low quality, especially incompleteness, impedes effective utilization of the reports for analyzing and learning. The lack of a completeness evaluation tool for narrative medication error reports is a barrier to improving the quality of reports. Moreover, no effective mechanisms are integrated in reporting systems for knowledge support upon reporting. In this study, we developed a minimal data model which defines necessary elements in narrative medication error reports and utilized it to evaluate patient safety organization (PSO) medication reports. This study holds promise in bridging the gap between the low quality of narrative reports and the needs of analyzing and learning from medication errors.