The How and Why of Incident Investigation: Implications for Health Information Technology

  • Marilyn Sue Bogner
Part of the Lecture Notes in Computer Science book series (LNCS, volume 4799)


The potential of health information technology to effectively support the work of health care providers and reduce the likelihood of errors and incidents has not been realized; however, the manner of investigating incidents can provide information to aid in its realization. Implications of negligible findings from extensive research on provider accountability for errors point to the importance of addressing the nature of error incidents. Consideration of the nature of incidents together with lessons learned from industry error research expands the focus of incident investigations to include how and why the event happened. A model to guide incident investigations and examples of the viability of that model to address issues in using health information technology are described. The wisdom of Sherlock Holmes accompanies this sleuthing for methods to enhance information technology to better support care providers in their daily work.


Incident Investigation Health Information Technology Error Behavior Systems User Support 


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Copyright information

© Springer-Verlag Berlin Heidelberg 2007

Authors and Affiliations

  • Marilyn Sue Bogner
    • 1
  1. 1.Institute for the Study of Human Error, LLC Bethesda, MD 

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