Abstract
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.
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References
Robert Wood Johnson Foundation: Health Information Technology in the United States: The Information Base for Progress. Executive Summary. Robert Wood Johnson Foundation, Washington D.C (2006)
Holzinger, A., Geierhofer, R., Errath, M.: Semantic Information in Medical Information Systems - from Data and Information to Knowledge: Facing Information Overload. In: Proc. of I-MEDIA 2007 and I-SEMANTICS 2007, pp. 323–330 (2007)
Holzinger, A.: Usability Engineering for Software Developers. Communications of the ACM 48(1), 71–74 (2005)
Holzinger, A., Errath, M.: Mobile computer Web-application design in medicine: some research based guidelines. Universal Access in the Information Society International Journal 6(1), 31–41 (2007)
Nebeker, J., Hoffman, J., Weir, C., et al.: High Rates of Adverse Drug Events in a Highly Computerized Hospital. Archives of Internal Medicine 165, 111–116 (2005)
Han, Y., Carcillo, J., Venkataraman, S., Clark, R., et al.: Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry System. Pediatrics 116, 1506–1511 (2005)
Mills, P., Neily, J., Mims, E., Burkhardt, M., Bagian, J.: Improving the Bar-Coded Medication Administration System at the Department of Veterans Affairs. American Journal of Health-System Pharmacists 63 (August 2006)
Rasmussen, J.: Human Error and the Problem of Causality in Analysis of Accidents. Philosophical Transactions of the Royal Society of London 337, 449–462 (1990)
Kohn, L., Corrigan, J., Donaldson, M. (eds.): To Err Is Human: Building a Safer Health System. National Academy Press, Washington (1999)
Expert Group on Learning from Adverse Events in the NHS (National Health Service): An Organization with a Memory. (last access, 2007 -08-31), http://www.dh.gov.uk/PublicationsAndStatistics/Publications/
Bosk, C.: Forgive and Remember: Managing Medical Failures. University of Chicago Press, Chicago (1979)
Reason, J.: Human Error. Cambridge University Press, New York (1991)
Gibson, R., Singh, J.: Wall of Silence: The Untold Story of the Medical Mistakes ThatKill and Injure Millions of Americans. Lifeline Press, Washington, D.C (2003)
Lewin, K.: Principles of Topological Psychology. McGraw-Hill, New York (1966)
Buckle, P., et al.: Issues in Health Care, International Ergonomics Meeting (2006)
Heider, F.: The Psychology of Interpersonal Relations. Wiley & Sons, New York (1958)
Rasmussen, J.: Human Errors: A Taxonomy for Describing Human Malfunction in Industrial Installations. Journal of Occupational Accidents 4, 311–333 (1982)
Senders, J., Moray, N.: Human Error: Cause, Prediction, and Reduction. Lawrence Erlbaum Associates, Inc, Mahwah (1991)
Moray, N.: Error Reduction as a Systems Problem. In: Bogner, M.S. (ed.) Human Error in Medicine, pp. 67–92. Lawrence Erlbaum Associates, Inc, Mahwah (1994)
Bogner, M.: A Systems Approach To Medical Error. In: Vincent, C., DeMol, B. (eds.) Safety in Medicine, pp. 83–100. Pergamon Press, Amsterdam (2000)
Lewin, K.: Behavior and Development as a Function of the Total Situation. In: Cartwright, D. (ed.) Field Theory In Social Science, pp. 238–303. Harper & Row, New York (1964)
Bogner, M.S.: Stretching The Search for the Why of Error: The Systems Approach. Journal of Clinical Engineering 27, 110–115 (2002)
Bogner, M.S.: Misadventures in Health Care:Inside Stories. In: Bogner, M.S. (ed.), pp. 41–58. Lawrence Erlbaum Associates, Inc, Mahwah (2004)
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Bogner, M.S. (2007). The How and Why of Incident Investigation: Implications for Health Information Technology. In: Holzinger, A. (eds) HCI and Usability for Medicine and Health Care. USAB 2007. Lecture Notes in Computer Science, vol 4799. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-76805-0_27
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DOI: https://doi.org/10.1007/978-3-540-76805-0_27
Publisher Name: Springer, Berlin, Heidelberg
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