An analysis of computer-related patient safety incidents to inform the development of a classification
Open Access
- 1 November 2010
- journal article
- Published by Oxford University Press (OUP) in Journal of the American Medical Informatics Association
- Vol. 17 (6), 663-670
- https://doi.org/10.1136/jamia.2009.002444
Abstract
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.This publication has 30 references indexed in Scilit:
- Safe Electronic Health Record Use Requires a Comprehensive Monitoring and Evaluation FrameworkJama-Journal Of The American Medical Association, 2010
- Prescription Errors and Outcomes Related to Inconsistent Information Transmitted Through Computerized Order EntryJAMA Internal Medicine, 2009
- The unintended consequences of computerized provider order entry: Findings from a mixed methods explorationInternational Journal of Medical Informatics, 2009
- Towards an International Classification for Patient Safety: key concepts and termsInternational Journal for Quality in Health Care, 2009
- Towards an International Classification for Patient Safety: a Delphi surveyInternational Journal for Quality in Health Care, 2009
- Towards an International Classification for Patient Safety: the conceptual frameworkInternational Journal for Quality in Health Care, 2009
- EHR Safety: The Way Forward to Safe and Effective SystemsJournal of the American Medical Informatics Association, 2008
- "e-Iatrogenesis": The Most Critical Unintended Consequence of CPOE and other HITJournal of the American Medical Informatics Association, 2007
- An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classificationBMJ Quality & Safety, 2006
- Types of Unintended Consequences Related to Computerized Provider Order EntryJournal of the American Medical Informatics Association, 2006