Document Detail


An analysis of computer-related patient safety incidents to inform the development of a classification.
MedLine Citation:
PMID:  20962128     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
OBJECTIVE: To analyze patient safety incidents associated with computer use to develop the basis for a classification of problems reported by health professionals.
DESIGN: Incidents submitted to a voluntary incident reporting database across one Australian state were retrieved and a subset (25%) was analyzed to identify 'natural categories' for classification. Two coders independently classified the remaining incidents into one or more categories. Free text descriptions were analyzed to identify contributing factors. Where available medical specialty, time of day and consequences were examined.
MEASUREMENTS: Descriptive statistics; inter-rater reliability.
RESULTS: A search of 42,616 incidents from 2003 to 2005 yielded 123 computer related incidents. After removing duplicate and unrelated incidents, 99 incidents describing 117 problems remained. A classification with 32 types of computer use problems was developed. Problems were grouped into information input (31%), transfer (20%), output (20%) and general technical (24%). Overall, 55% of problems were machine related and 45% were attributed to human-computer interaction. Delays in initiating and completing clinical tasks were a major consequence of machine related problems (70%) whereas rework was a major consequence of human-computer interaction problems (78%). While 38% (n=26) of the incidents were reported to have a noticeable consequence but no harm, 34% (n=23) had no noticeable consequence.
CONCLUSION: Only 0.2% of all incidents reported were computer related. Further work is required to expand our classification using incident reports and other sources of information about healthcare IT problems. Evidence based user interface design must focus on the safe entry and retrieval of clinical information and support users in detecting and correcting errors and malfunctions.
Authors:
Farah Magrabi; Mei-Sing Ong; William Runciman; Enrico Coiera
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Publication Detail:
Type:  Journal Article; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  Journal of the American Medical Informatics Association : JAMIA     Volume:  17     ISSN:  1527-974X     ISO Abbreviation:  J Am Med Inform Assoc     Publication Date:    2010 Nov-Dec
Date Detail:
Created Date:  2010-10-21     Completed Date:  2011-02-18     Revised Date:  2011-11-08    
Medline Journal Info:
Nlm Unique ID:  9430800     Medline TA:  J Am Med Inform Assoc     Country:  United States    
Other Details:
Languages:  eng     Pagination:  663-70     Citation Subset:  IM    
Affiliation:
Centre for Health Informatics, University of New South Wales, Sydney, Australia. f.magrabi@unsw.edu.au
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MeSH Terms
Descriptor/Qualifier:
Australia
Computer Systems*
Equipment Failure Analysis*
Humans
Information Storage and Retrieval*
Medical Errors / statistics & numerical data
Medical Informatics*
Risk Management / classification*
User-Computer Interface

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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