A user needs assessment to inform health information exchange design and implementation.

BACKGROUND: Important barriers for widespread use of health information exchange (HIE) are usability and interface issues. However, most HIEs are implemented without performing a needs assessment with the end users, healthcare providers. We performed a user needs assessment for the process of obtaining clinical information from other health care organizations about a hospitalized patient and identified the types of information most valued for medical decision-making. METHODS: Quantitative and qualitative analysis were used to evaluate the process to obtain and use outside clinical information (OI) using semi-structured interviews (16 internists), direct observation (750 h), and operational data from the electronic medical records (30,461 hospitalizations) of an internal medicine department in a public, teaching hospital in Tampa, Florida. RESULTS: 13.7 % of hospitalizations generate at least one request for OI. On average, the process comprised 13 steps, 6 decisions points, and 4 different participants. Physicians estimate that the average time to receive OI is 18 h. Physicians perceived that OI received is not useful 33-66 % of the time because information received is irrelevant or not timely. Technical barriers to OI use included poor accessibility and ineffective information visualization. Common problems with the process were receiving extraneous notes and the need to re-request the information. Drivers for OI use were to trend lab or imaging abnormalities, understand medical history of critically ill or hospital-to-hospital transferred patients, and assess previous echocardiograms and bacterial cultures. About 85 % of the physicians believe HIE would have a positive effect on improving healthcare delivery. CONCLUSIONS: Although hospitalists are challenged by a complex process to obtain OI, they recognize the value of specific information for enhancing medical decision-making. HIE systems are likely to have increased utilization and effectiveness if specific patient-level clinical information is delivered at the right time to the right users.

Clustering-based methodology for analyzing near-miss reports and identifying risks in healthcare delivery.

Near-miss reports are qualitative descriptions of events that could have harmed patients but did not due to a timely intervention or a convenient evolution of the circumstances. Near-miss reporting has increasingly become a relevant tool to support patient safety efforts since they provide some evidence of risk in the system before patients suffer adverse consequences. Near-misses are usually classified into pre-specified categories that correspond to sources of risk in the system or its processes. Their analysis often consists of tallying classified near-misses to determine risk priorities based on frequency within each pre-specified risk category. Our research aims to use different combinations of near-miss reports to find potential sources of risk. We propose an unsupervised bisecting k-prototypes algorithm for clustering coded near-miss reports to identify relationships between events that would not otherwise have been easily identified. Subsequent study of resulting clusters will lead to the identification of potentially dangerous, but unsuspected system interactions. We illustrate or methodology with preliminary results of its implementation at the University of South Florida Health clinics.

Human error, not communication and systems, underlies surgical complications.

OBJECTIVE: This study prospectively assesses the underlying errors contributing to surgical complications over a 12-month period in a complex academic department of surgery using a validated scoring template. BACKGROUND: Studies in "high reliability organizations" suggest that systems failures are responsible for errors. Reports from the aviation industry target communication failures in the cockpit. No prior studies have developed a validated classification system and have determined the types of errors responsible for surgical complications. METHODS: A classification system of medical error during operation was created, validated, and data collected on the frequency, type, and severity of medical errors in 9,830 surgical procedures. Statistical analysis of concordance, validity, and reliability were performed. RESULTS: Reported major complications occurred in 332 patients (3.4%) with error in 78.3%: errors in surgical technique (63.5%), judgment errors (29.6%), inattention to detail (29.3%), and incomplete understanding (22.7%). Error contributed more than 50% to the complication in 75%. A total of 13.6% of cases had error but no injury, 34.4% prolongation of hospitalization, 25.1% temporary disability, 8.4% permanent disability, and 16.0% death. In 20%, the error was a "mistake" (the wrong thing), and in 58% a "slip" (the right thing incorrectly). System errors (2%) and communication errors (2%) were infrequently identified. CONCLUSIONS: After surgical technique, most surgical error was caused by human factors: judgment, inattention to detail, and incomplete understanding, and not to organizational/system errors or breaks in communication. Training efforts to minimize error and enhance patient safety must address human factor causes of error.

Combating the stress of residency: one school's approach.

Residency is a time of stress and turmoil for many residents. The stresses are varied and great, often involving both personal and professional issues. One institutional mechanism that has been shown to help residents cope with stress is the use of residents' wellness, or assistance, programs. The University of South Florida (USF) College of Medicine developed the USF Residency Assistance Program (RAP) in 1997, modeled after business employee assistance programs but tailored to enhance the well-being of residents. The program was developed in an organized, thoughtful manner starting with a Request for Proposals to all local employee assistance programs and the selection of one of these to run the program. The RAP is broad-based, readily available, easily accessible, totally voluntary and confidential, and not reportable to the state board of medicine. It is well integrated into all residency programs and has had excellent acceptance from the administration; information about access to the RAP is available to all residents through multiple venues. The cost is minimal, at only seven cents a day per resident. The authors present data from the eight years the RAP has been operating, including information on program use, referral rates, acceptance, and types of problems encountered. One suicide occurred during this time period, and the RAP provided a significant role in grief counseling. Assistance programs are critical to the well-being of residents. The USF program presents a model that can be used by other programs around the country.