Technology, governance and patient safety: systems issues in technology and patient safety

The Incidence and Nature of Adverse Medical Device Events in Dutch Hospitals: A Retrospective Patient Record Review Study

OBJECTIVES

Despite widespread use of medical devices and their increasing complexity, their contribution to unintended injury caused by healthcare (adverse events, AEs) remains relatively understudied. The aim of this study was to gain insight in the incidence and types of AEs involving medical devices (AMDEs).

METHODS

Data from two patient record studies for the identification of AEs were used. Identification of AMDEs was part of these studies. Patient records of 6894 admissions of a random sample of 20 hospitals in 2011/2012 and 19 hospitals in 2015/2016 were reviewed for AMDEs by trained nurses and physicians.

RESULTS

In 98.7% of the admissions, a medical device was used. Adverse events involving medical devices were present in 2.8% of the admissions, with 24% of the AMDEs being potentially preventable. Of all AEs, in 40%, medical devices were involved. Of all potentially preventable AEs, in 44%, medical devices were involved. Implants were most often involved in potentially preventable AMDEs.

CONCLUSIONS

Medical devices are substantially involved in potentially preventable AEs in hospitals. Research into AMDEs is of great importance because of the increasing use and complexity of medical devices. Based on patient records, most improvements could be made for placement of implants and prevention of infections related to medical devices. Safety and safe use of medical devices should be a subject of attention and further research.

Assessing Laparoscopic Surgical Skills Using Similarity Network Models: A Pilot Study

Background: Medical devices are becoming more complex, and doctors need to learn quickly how to use new medical tools. However, it is challenging to objectively assess the fundamental laparoscopic surgical skill level and determine skill readiness for advancement. There is a lack of objective models to compare performance between medical trainees and experienced doctors. Methods: This article discusses the use of similarity network models for individual tasks and a combination of tasks to show the level of similarity between residents and medical students while performing each task and their overall laparoscopic surgical skill level using a medical device (eg laparoscopic instruments). When a medical student is connected to most residents, that student is competent to the next training level. Performance of sixteen participants (5 residents and 11 students) while performing 3 tasks in 3 different training schedules is used in this study. Results: The promising result shows the general positive progression of students over 4 training sessions. Our results also indicate that students with different training schedules have different performance levels. Students' progress in performing a task is quicker if the training sessions are held more closely compared to when the training sessions are far apart in time. Conclusions: This study provides a graph-based framework for evaluating new learners' performance on medical devices and their readiness for advancement. This similarity network method could be used to classify students' performance using similarity thresholds, facilitating decision-making related to training and progression through curricula.

Using simulation to explore the impact of device design on the learning and performance of peripheral intravenous cannulation

BACKGROUND

The design of medical devices impacts upon the performance of healthcare professionals and patient safety. However, multiple devices serving the same function are often available. The purpose of this study was to use simulation as a means of examining the impact of differences in device design on (1) learning of, or attainment of behavioral fluency in, peripheral intravenous cannulation (PIVC); and (2) the generalization, or transfer, of learning on one device to performance of PIVC using an untrained device.

METHODS

A total of 25 final cycle medical students participated in this study which used a randomized two-group design. Participants were randomly assigned to learn PIVC using either a closed PIVC device (a single device which consists of an intravenous cannula with a pre-attached extension tube; n = 14) or an open PIVC device (a two-piece device made up of an intravenous cannula and a separate extension tube which is attached following insertion of the cannula; n = 11). Task analyses were developed for the performance of PIVC using each device. Subsequently, simulation-based fluency training was delivered to both groups using their assigned PIVC device, and continued for each participant until the fluency criterion was achieved. Following achievement of fluency, participants were asked to perform PIVC using the untrained device (i.e., the PIVC device that they had not been trained on).

RESULTS

All participants in both groups met the fluency criterion, and no significant differences were observed in the number of trials or total training required by groups to achieve fluency. Participants in both groups improved significantly from baseline (M = 11.69) to final training trial (M = 100). However, a significant decrement in performance (M = 81.5) was observed when participants were required to perform PIVC using the untrained device.

CONCLUSIONS

Participants achieved fluency in PIVC regardless of the device used. However, significant decrements in performance were observed when participants were required to perform PIVC using a novel device. This finding supports the need for careful consideration of devices purchased and supplied in the clinical setting, and the need for training prior to the introduction of novel devices or for new staff members.

New technology and the chain of safety

Healthcare is currently experiencing an exponential growth in medical technology but it has not kept pace with similar industries such as the airline industry. New technology has the potential to improve patient safety, but if the introduction of new technology into the healthcare setting is not coordinated in a thoughtful, proactive manner, there may be weak links in the chain of safety that may expose risks for patients. We describe three concepts that represent this chain of safety. We suggest that these are shared among all leadership and frontline staff and that these concepts require their full attention and investment in order to keep the chain of safety intact and avoid a single weak link in implementing new technology.

Les nouvelles technologies et la chaîne de la sécurité

La technologie médicale connaît une croissance exponentielle dans le milieu de la santé, mais elle n'a toutefois pas suivi le rythme observé dans des industries similaires, telles que l'aéronautique. Les nouvelles technologies ont le potentiel d'accroître la sécurité des patients, mais si leur introduction dans le milieu de la santé n'est pas coordonnée de manière réfléchie et proactive, la chaîne de la sécurité risque de s'en trouver affaiblie, ce qui exposera les patients à des risques. Trois concepts qui représentent la chaîne de la sécurité sont décrits. Les équipes de direction et le personnel de première ligne devraient tous les connaître, les étudier et s'y investir afin de maintenir la chaîne de la sécurité intacte et d'éviter qu'un seul maillon soit affaibli par l'adoption d'une nouvelle technologie.

Toward safer health care: a review strategy of FDA medical device adverse event database to identify and categorize health information technology related events

Introduction

Health information technology (HIT) is intended to provide safer and better care to patients. However, poorly designed or implemented HIT poses a key risk to patient safety. It is essential for healthcare providers and researchers to investigate the HIT-related events. Unfortunately, the lack of HIT-related event databases in the community hinders the analysis and management of HIT-related events.

Objectives

Develop a standardized process for identifying HIT-related events from a Federal Drug Administration (FDA) database in order to create an HIT exclusive database for analysis and learning.

Methods

The FDA Manufacturer and User Facility Device Experience (MAUDE) database, containing over 7-million reports about medical device malfunctions and problems leading to serious injury or death, was considered as a potential resource to identify HIT-related events. We developed a strategy of identifying and categorizing HIT-related events from the FDA reports through the application of a keyword filter and standardized expert review. Ten percent identified reports were reviewed to measure the consistency among experts and to initialize a database for HIT-related events.

Results

With the proposed strategy, we initialized an HIT-related event database with over 3500 reports, and updated the estimation of the HIT-related event proportion in the FDA MAUDE database to 0.46∼0.69%, up to 50,000 HIT-related events.

Conclusion

The proposed strategy for HIT-related event identification holds promise in aiding the understanding, characterization, discovery, and reporting of HIT-related events toward improved patient safety. The analysis of contributing factors under the 8-dimensional sociotechnical model shows that hardware and software, clinical content, and human-computer interface were identified more frequently than the other dimensions.

Assessing the Status Quo of EHR Accessibility, Usability, and Knowledge Dissemination

Aim:

This study was performed to better characterize accessibility to electronic health records (EHRs) among informatics professionals in various roles, settings, and organizations across the United States and internationally.

Background:

The EHR landscape has evolved significantly in recent years, though challenges remain in key areas such as usability. While patient access to electronic health information has gained more attention, levels of access among informatics professionals, including those conducting usability research, have not been well described in the literature. Ironically, many informatics professionals whose aim is to improve EHR design have restrictions on EHR access or publication, which interfere with broad dissemination of findings in areas of usability research.

Methods:

To quantify the limitations on EHR access and publication rights, we conducted a survey of informatics professionals from a broad spectrum of roles including practicing clinicians, researchers, administrators, and members of industry. Results were analyzed and levels of EHR access were stratified by role, organizational affiliation, geographic region, EHR type, and restrictions with regard to publishing results of usability testing, including screenshots.

Results:

126 respondents completed the survey, representing all major geographic regions in the United States. 71.5 percent of participants reported some level of EHR access, while 13 percent reported no access whatsoever. Rates of no-access were higher among faculty members and researchers (19 percent). Among faculty members and researchers, 72 percent could access the EHR for usability and/or research purposes, but, of those, fewer than 1 in 3 could freely publish screenshots with results of usability testing and half could not publish such data at all. Across users from all roles, only 21 percent reported the ability to publish screenshots freely without restrictions.

Conclusions:

This study offers insight into current patterns of EHR accessibility among informatics professionals, highlighting restrictions that limit dissemination of usability research and testing. Further conversations and shared responsibility among the various stakeholders in industry, government, health care organizations, and informatics professionals are vital to continued EHR optimization.

EXPLORING MEDICAL DEVICES: THE USE OF RISK ASSESSMENT TOOLS AND THEIR LINK WITH TRAINING IN HOSPITALS

OBJECTIVES

The aim of this study was to explore the risk assessment tools and criteria used to assess the risk of medical devices in hospitals, and to explore the link between the risk of a medical device and how those risks impact or alter the training of staff.

METHODS

Within a broader questionnaire on implementation of a national guideline, we collected quantitative data regarding the types of risk assessment tools used in hospitals and the training of healthcare staff.

RESULTS

The response rate for the questionnaire was 81 percent; a total of sixty-five of eighty Dutch hospitals. All hospitals use a risk assessment tool and the biggest cluster (40 percent) use a tool developed internally. The criteria used to assess risk most often are: the function of the device (92 percent), the severity of adverse events (88 percent) and the frequency of use (77 percent). Forty-seven of fifty-six hospitals (84 percent) base their training on the risk associated with a medical device. For medium- and high-risk devices, the main method is practical training. As risk increases, the amount and type of training and examination increases.

CONCLUSIONS

Dutch hospitals use a wide range of tools to assess the risk of medical devices. These tools are often based on the same criteria: the function of the device, the potential severity of adverse events, and the frequency of use. Furthermore, these tools are used to determine the amount and type of training required for staff. If the risk of a device is higher, then the training and examination is more extensive.

Improving the redistribution of the security lessons in healthcare: An evaluation of the Generic Security Template

CONTEXT

The recurrence of past security breaches in healthcare showed that lessons had not been effectively learned across different healthcare organisations. Recent studies have identified the need to improve learning from incidents and to share security knowledge to prevent future attacks. Generic Security Templates (GSTs) have been proposed to facilitate this knowledge transfer. The objective of this paper is to evaluate whether potential users in healthcare organisations can exploit the GST technique to share lessons learned from security incidents.

METHODOLOGY

We conducted a series of case studies to evaluate GSTs. In particular, we used a GST for a security incident in the US Veterans' Affairs Administration to explore whether security lessons could be applied in a very different Chinese healthcare organisation.

RESULTS

The results showed that Chinese security professional accepted the use of GSTs and that cyber security lessons could be transferred to a Chinese healthcare organisation using this approach. The users also identified the weaknesses and strengths of GSTs, providing suggestions for future improvements.

CONCLUSION

Generic Security Templates can be used to redistribute lessons learned from security incidents. Sharing cyber security lessons helps organisations consider their own practices and assess whether applicable security standards address concerns raised in previous breaches in other countries. The experience gained from this study provides the basis for future work in conducting similar studies in other healthcare organisations.

Review of Social and Organizational Issues in Health Information Technology

Objectives

This paper reviews organizational and social issues (OSIs) in health information technology (HIT).

Methods

A review and synthesis of the literature on OSIs in HIT was conducted.

Results

Five overarching themes with respect to OSIs in HIT were identified and discussed: scope and frameworks for defining OSIs in HIT, context matters, process immaturity and complexity, trade-offs will happen and need to be discussed openly, and means of studying OSIs in HIT.

Conclusions

There is a wide body of literature that provides insight into OSIs in HIT, even if many of the studies are not explicitly labelled as such. The two biggest research needs are more explicit and theoretical studies of OSI in HITs and more research on integrating micro and macro perspectives of HIT use in organizations.

Use of data mining at the Food and Drug Administration

Objectives This article summarizes past and current data mining activities at the United States Food and Drug Administration (FDA).

Target audience We address data miners in all sectors, anyone interested in the safety of products regulated by the FDA (predominantly medical products, food, veterinary products and nutrition, and tobacco products), and those interested in FDA activities.

Scope Topics include routine and developmental data mining activities, short descriptions of mined FDA data, advantages and challenges of data mining at the FDA, and future directions of data mining at the FDA.

How can we improve the recognition, reporting and resolution of medical device-related incidents in hospitals? A qualitative study of physicians and registered nurses

BACKGROUND

To explore factors that influence and to identify initiatives to improve the recognition, reporting and resolution of device-related incidents.

METHODS

Semi-structured telephone interviews with 16 health professionals in two tertiary care hospitals were conducted. Purposive sampling was used to identify appropriate study participants. Transcribed interviews were read independently by one individual to identify, define and organize themes and verified by another reviewer.

RESULTS

Themes related to incident recognition were the hospital staff's knowledge and professional experience, medical device performance and clinical manifestations of patients, while incident reporting was influenced by error severity, personal attitudes of clinicians, feedback received on the error reported. Physicians often discontinued using medical devices if they malfunctioned. Education and training and the implementation of registries were discussed as important initiatives to improve medical device surveillance in clinical practice.

CONCLUSIONS

Results from the telephone interviews suggest that multiple factors that influence participation in medical device surveillance activities are consistent with results for medical errors as reported in previous studies. The study results helped to propose a conceptual framework for a medical device surveillance system in a hospital context that would enhance patient safety and health care delivery.

Patient safety risks associated with telecare: a systematic review and narrative synthesis of the literature

Background

Patient safety risk in the homecare context and patient safety risk related to telecare are both emerging research areas. Patient safety issues associated with the use of telecare in homecare services are therefore not clearly understood. It is unclear what the patient safety risks are, how patient safety issues have been investigated, and what research is still needed to provide a comprehensive picture of risks, challenges and potential harm to patients due to the implementation and use of telecare services in the home. Furthermore, it is unclear how training for telecare users has addressed patient safety issues. A systematic review of the literature was conducted to identify patient safety risks associated with telecare use in homecare services and to investigate whether and how these patient safety risks have been addressed in telecare training.

Methods

Six electronic databases were searched in addition to hand searches of key items, reference tracking and citation tracking. Strict inclusion and exclusion criteria were set. All included items were assessed according to set quality criteria and subjected to a narrative synthesis to organise and synthesize the findings. A human factors systems framework of patient safety was used to frame and analyse the results.

Results

22 items were included in the review. 11 types of patient safety risks associated with telecare use in homecare services emerged. These are in the main related to the nature of homecare tasks and practices, and person-centred characteristics and capabilities, and to a lesser extent, problems with the technology and devices, organisational issues, and environmental factors. Training initiatives related to safe telecare use are not described in the literature.

Conclusions

There is a need to better identify and describe patient safety risks related to telecare services to improve understandings of how to avoid and minimize potential harm to patients. This process can be aided by reframing known telecare implementation challenges and user experiences of telecare with the help of a human factors systems approach to patient safety.

An analysis of electronic health record-related patient safety concerns

OBJECTIVE

A recent Institute of Medicine report called for attention to safety issues related to electronic health records (EHRs). We analyzed EHR-related safety concerns reported within a large, integrated healthcare system.

METHODS

The Informatics Patient Safety Office of the Veterans Health Administration (VA) maintains a non-punitive, voluntary reporting system to collect and investigate EHR-related safety concerns (ie, adverse events, potential events, and near misses). We analyzed completed investigations using an eight-dimension sociotechnical conceptual model that accounted for both technical and non-technical dimensions of safety. Using the framework analysis approach to qualitative data, we identified emergent and recurring safety concerns common to multiple reports.

RESULTS

We extracted 100 consecutive, unique, closed investigations between August 2009 and May 2013 from 344 reported incidents. Seventy-four involved unsafe technology and 25 involved unsafe use of technology. A majority (70%) involved two or more model dimensions. Most often, non-technical dimensions such as workflow, policies, and personnel interacted in a complex fashion with technical dimensions such as software/hardware, content, and user interface to produce safety concerns. Most (94%) safety concerns related to either unmet data-display needs in the EHR (ie, displayed information available to the end user failed to reduce uncertainty or led to increased potential for patient harm), software upgrades or modifications, data transmission between components of the EHR, or 'hidden dependencies' within the EHR.

DISCUSSION

EHR-related safety concerns involving both unsafe technology and unsafe use of technology persist long after 'go-live' and despite the sophisticated EHR infrastructure represented in our data source. Currently, few healthcare institutions have reporting and analysis capabilities similar to the VA.

CONCLUSIONS

Because EHR-related safety concerns have complex sociotechnical origins, institutions with long-standing as well as recent EHR implementations should build a robust infrastructure to monitor and learn from them.

Technological affordances of risk and blame: the case of the electronic prescription service in England

Information and communication technology (ICT) is often presented by health policymakers and software designers as a means for reducing clinical risk, leading to safer clinical practice. Studies have challenged this view, showing how technology can produce new or unanticipated risks. Although research seeks to objectively identify these risks, we recognise that technological risks are socially constructed through the interaction of technology and practice. The aim of this article is to explore how technology affords opportunities for the social construction and control of risk in health care settings. Drawing upon a study of the electronic prescription service introduced in the National Health Service in England, we make three arguments. Firstly, as technology interacts with social practice (for example, through policy and the design and use of ICT) it affords opportunities for the construction of risk through its interpretive flexibility, transformative capacity and materiality. Secondly, social actors interpret these risks within and across professional boundaries and cultures. Thirdly, the social construction of risk affords certain implications to policymakers, designers and users of health ICT, specifically a reordering of power and responsibility and a recasting of questions of blame. These, in turn, raise questions concerning the boundaries and bearers of responsibility.

Exploring the sociotechnical intersection of patient safety and electronic health record implementation

OBJECTIVE

The intersection of electronic health records (EHR) and patient safety is complex. To examine the applicability of two previously developed conceptual models comprehensively to understand safety implications of EHR implementation in the English National Health Service (NHS).

METHODS

We conducted a secondary analysis of interview data from a 30-month longitudinal, prospective, case study-based evaluation of EHR implementation in 12 NHS hospitals. We used a framework analysis approach to apply conceptual models developed by Sittig and Singh to understand better EHR implementation and use: an eight-dimension sociotechnical model and a three-phase patient safety model (safe technology, safe use of technology, and use of technology to improve safety).

RESULTS

The intersection of patient safety and EHR implementation and use was characterized by risks involving technology (hardware and software, clinical content, and human-computer interfaces), the interaction of technology with non-technological factors, and improper or unsafe use of technology. Our data support that patient safety improvement activities as well as patient safety hazards change as an organization evolves from concerns about safe EHR functionality, ensuring safe and appropriate EHR use, to using the EHR itself to provide ongoing surveillance and monitoring of patient safety.

DISCUSSION

We demonstrate the face validity of two models for understanding the sociotechnical aspects of safe EHR implementation and the complex interactions of technology within a healthcare system evolving from paper to integrated EHR.

CONCLUSIONS

Using sociotechnical models, including those presented in this paper, may be beneficial to help stakeholders understand, synthesize, and anticipate risks at the intersection of patient safety and health information technology.

Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting

OBJECTIVE

Recent critiques of incident reporting suggest that its role in managing safety has been over emphasized. The objective of this study was to examine the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences.

DESIGN

Qualitative research design using documentary analysis and semi-structured interviews.

SETTING

Two large teaching hospitals in London; one providing acute and the other mental healthcare.

PARTICIPANTS

Sixty-two healthcare practitioners with experience of reporting and analysing incidents.

RESULTS

Incident reporting was perceived as having a positive effect on safety, not only by leading to changes in care processes but also by changing staff attitudes and knowledge. Staff discussed examples of both instrumental and conceptual uses of the knowledge generated by incident reports. There are difficulties in using incident reports to improve safety in healthcare at all stages of the incident reporting process. Differences in the risks encountered and the organizational systems developed in the two hospitals to review reported incidents could be linked to the differences we found in attitudes to incident reporting between the two hospitals.

CONCLUSION

Incident reporting can be a powerful tool for developing and maintaining an awareness of risks in healthcare practice. Using incident reports to improve care is challenging and the study highlighted the complexities involved and the difficulties faced by staff in learning from incident data.

Smart wearable systems: current status and future challenges

OBJECTIVE

Extensive efforts have been made in both academia and industry in the research and development of smart wearable systems (SWS) for health monitoring (HM). Primarily influenced by skyrocketing healthcare costs and supported by recent technological advances in micro- and nanotechnologies, miniaturisation of sensors, and smart fabrics, the continuous advances in SWS will progressively change the landscape of healthcare by allowing individual management and continuous monitoring of a patient's health status. Consisting of various components and devices, ranging from sensors and actuators to multimedia devices, these systems support complex healthcare applications and enable low-cost wearable, non-invasive alternatives for continuous 24-h monitoring of health, activity, mobility, and mental status, both indoors and outdoors. Our objective has been to examine the current research in wearable to serve as references for researchers and provide perspectives for future research.

METHODS

Herein, we review the current research and development of and the challenges facing SWS for HM, focusing on multi-parameter physiological sensor systems and activity and mobility measurement system designs that reliably measure mobility or vital signs and integrate real-time decision support processing for disease prevention, symptom detection, and diagnosis. For this literature review, we have chosen specific selection criteria to include papers in which wearable systems or devices are covered.

RESULTS

We describe the state of the art in SWS and provide a survey of recent implementations of wearable health-care systems. We describe current issues, challenges, and prospects of SWS.

CONCLUSION

We conclude by identifying the future challenges facing SWS for HM.

Patient safety in the critical care environment

Improving the quality and safety of intensive care unit (ICU) care in the United States is a significant challenge for the future. Obtaining improvement in systems of care is difficult given the reactionary mode physicians tend to enter when dealing with moment-to-moment crises. It will be important to implement quality and safety measures that are already supported by evidence. Improvement of device safety will be critical to reducing the large number of device-related complications that occur in US ICUs. Prospective collection of adverse events with rigorous analysis will be important to allow systematic errors to be exposed and corrected.

Exploring the Effect of mHealth Technologies on Communication and Information Sharing in a Pediatric Critical Care Unit

Communication and information sharing is an important aspect of healthcare information technology and mHealth management. A main requirement in the quality of patient care is the ability of all health care participants to communicate. Research illustrates that the complexity of communicating within the health care system hinders the quality of health care service delivery. Health informatics have been touted as a way to improve communication deficiencies, which has led to the exponential growth of health informatics integration. However, research still lags in understanding how health informatics affects patient care, health professional work routines, and the overall health care system. This study investigates the extent to which mHealth technologies influence communication information sharing patterns between interdisciplinary health care providers in the delivery of health care services. This study was conducted at Hamilton Health Sciences and through a sociotechnical approach, focuses on both the end user’s experiences with mHealth in daily work communication scenarios, and the extent to which mHealth use affects interdisciplinary communication. Results indicate that there are several mitigating factors which influence communication patterns using mHealth technologies, including: information sharing, mobility, ergonomic and system design.

[Not Available]

CONTEXT

Few data are available on the use and consequences of decentralized automated dispensing cabinets (ADCs) in institutional settings.

METHOD

This descriptive study examined compliance with published guidelines on the implementation of decentralized ADCs. The primary objective was to evaluate overall compliance, as well as compliance with specific steps in the medication cycle. The study was carried out at the Centre hospitalier universitaire (CHU) Sainte-Justine, a 500-bed mother-and-child hospital. The 2008 guidelines of the Institute for Safe Medication Practices (US) concerning the safe use of decentralized ADCs and the associated self-assessment tool (2009) were used to evaluate compliance at 30 days and at 120 days after implementation.

RESULTS

From November 2009 to April 2010, 7 decentralized ADCs were brought into service at the CHU Sainte-Justine. Overall compliance with published guidelines increased from 66% to 74% between January and April 2010. For each process related to the safe use of the ADCs, the criteria were briefly described, along with the non-compliance components related to technological or organizational aspects of implementation. For each component for which practice was noncompliant with guidelines, the actions required to modify the equipment (i.e., technological aspects) were determined and conveyed to the manufacturer; similarly, modes of use requiring modification (i.e., organizational aspects) were determined and conveyed to the institution.

CONCLUSION

This study has described the compliance of practices at the CHU Sainte-Justine with published guidelines of the Institute for Safe Medication Practices. The use of published guidelines can help to guide both the technological and organizational aspects of implementing decentralized ADCs. [Publisher's translation].

A critical review of the systems approach within patient safety research

The application of concepts, theories and methods from systems ergonomics within patient safety has proved to be an expanding area of research and application in the last decade. This paper aims to take a step back and examine what types of research have been conducted so far and use the results to suggest new ways forward. An analysis of a selection of the patient safety literature suggests that research has so far focused on human error, frameworks for safety and risk and incident reporting. The majority of studies have addressed system concerns at an individual level of analysis with only a few analysing systems across multiple system boundaries. Based on the findings, it is argued that future research needs to move away from a concentration on errors and towards an examination of the connections between systems levels. Examples of how this could be achieved are described in the paper. The outcomes from the review of the systems approach within patient safety provide practitioners and researchers within health care (e.g. the UK National Health Service) with a picture of what types of research are currently being investigated, gaps in understanding and possible future ways forward.

The health information system security threat lifecycle: an informatics theory

PURPOSE

This manuscript describes the health information system security threat lifecycle (HISSTL) theory. The theory is grounded in case study data analyzing clinicians' health information system (HIS) privacy and security (P&S) experiences in the practice context.

METHODS

The 'questerview' technique was applied to this study of 26 clinicians situated in 3 large Australian (across Victoria) teaching hospitals. Questerviews rely on data collection that apply standardized questions and questionnaires during recorded interviews. Analysis (using Nvivo) involved the iterative scrutiny of interview transcripts to identify emergent themes.

RESULTS

Issues including poor training, ambiguous legal frameworks containing punitive threats, productivity challenges, usability errors and the limitations of the natural hospital environment emerged from empirical data about the clinicians' HIS P&S practices. The natural hospital environment is defined by the permanence of electronic HISs (e-HISs), shared workspaces, outdated HIT infrastructure, constant interruption, a P&S regulatory environment that is not conducive to optimal training outcomes and budgetary constraints. The evidence also indicated the obtrusiveness, timeliness, and reliability of P&S implementations for clinical work affected participant attitudes to, and use of, e-HISs.

CONCLUSION

The HISSTL emerged from the analysis of study evidence. The theory embodies elements such as the fiscal, regulatory and natural hospital environments which impede P&S implementations in practice settings. These elements conflict with improved patient care outcomes. Efforts by clinicians to avoid conflict and emphasize patient care above P&S tended to manifest as security breaches. These breaches entrench factors beyond clinician control and perpetuate those within clinician control. Security breaches of health information can progress through the HISSTL. Some preliminary suggestions for addressing these issues are proposed.

STUDY LIMITATIONS

Legislative frameworks that are not related to direct patient care were excluded from this study. Other limitations included an exclusive focus on patient care tasks post-admission and pre-discharge from public hospital wards. Finally, the number of cases was limited by the number of participants who volunteered to participate in the study. It is reasonable to assume these participants were more interested in the P&S of patient care work than their counterparts, though the study was not intended to provide quantitative or statistical data. Nonetheless, additional case studies would strengthen the HISSTL theory if confirmatory, practice-based evidence were found.

The nature and occurrence of registration errors in the emergency department

Research into the nature and occurrence of medical errors has shown that these often result from a combination of factors that lead to the breakdown of workflow. Nowhere is this more critical than in the emergency department (ED), where the focus of clinical decisions is on the timely evaluation and stabilization of patients. This paper reports on the nature of errors and their implications for patient safety in an adult ED, using methods of ethnographic observation, interviews, and think-aloud protocols. Data were analyzed using modified "grounded theory," which refers to a theory developed inductively from a body of data. Analysis revealed four classes of errors, relating to errors of misidentification, ranging from multiple medical record numbers, wrong patient identification or address, and in one case, switching of one patient's identification information with those of another. Further analysis traced the root of the errors to ED registration. These results indicate that the nature of errors in the emergency department are complex, multi-layered and result from an intertwined web of activity, in which stress in the work environment, high patient volume and the tendency to adopt shortcuts play a significant role. The need for information technology (IT) solutions to these problems as well as the impact of alternative policies is discussed.

Incident reporting schemes and the need for a good story

Incident reporting is a central strategy for improving safety in the NHS (UK National Health Service). In this paper we discuss incident reporting in anaesthesia. We discuss four schemes for reporting: longstanding, departmental based schemes; newer, hospital wide schemes; a national scheme; and an inter-departmental scheme (developed by the authors). We also discuss an example report. We argue that this example report gives an expert 'story' of an incident, describing the incident in a way that is useful for the practical activities of maintaining and improving safety. We argue that stories are told and retold in reporting schemes. The reporting schemes are not just there to collect data but to afford the stories of what went wrong. In turn these schemes must be afforded stories by the anaesthetists, safety managers and the organisation at large. We consider how schemes can be designed to afford a 'good' story, one that is useful for the maintaining and improvement of safety.