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Jt Comm J Qual Patient Saf ; 42(2): 70-6, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26803035


BACKGROUND: An understanding of how health information technology (health IT) can contribute to sentinel events is necessary to learn how to safely implement and use health IT. An analysis was conducted to explore how health IT may contribute to adverse events that result in death or severe harm to the patient. METHODS: For 3,375 de-identified sentinel events voluntarily reported to The Joint Commission between January 1, 2010, and June 30, 2013, categorical and keyword queries were used to search for potential health IT-related events. Each of the identified events was reviewed on the basis of findings from root cause analyses (RCAs) to determine if health IT contributed to or caused the event, and if so, how and why. The contributing factors were classified using a composite of existing classification schemes. RESULTS: A total of 120 health IT-related sentinel events (affecting 125 patients) were identified. More than half resulted in patient death, 30% resulted in unexpected or additional care, and 11% resulted in permanent loss of function. The three most frequently identified event types were (1) medication errors, (2) wrong-site surgery (including the wrong side, wrong procedure, and wrong patient), and (3) delays in treatment. Contributing factors were most frequently associated with the human-computer interface, workflow and communication, and clinical content-related issues. CONCLUSIONS: The classification of health IT-related contributing factors indicates that health IT-related events are primarily associated with the sociotechnical dimensions of human-computer interface, workflow and communication, and clinical content. Improved identification of health IT-related contributing factors in the context of the sociotechnical dimensions may help software developers, device manufacturers, and end users in health care organizations proactively identify vulnerabilities and hazards, ultimately reducing the risk of harm to patients.

Sistemas de Informação/estatística & dados numéricos , Erros Médicos/estatística & dados numéricos , Comunicação , Computadores , Humanos , Erros Médicos/classificação , Erros de Medicação/estatística & dados numéricos , Políticas , Análise de Causa Fundamental , Vigilância de Evento Sentinela , Software , Fatores de Tempo , Fluxo de Trabalho
Int J Qual Health Care ; 23(6): 697-704, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21840943


OBJECTIVE: To assess perceptions about the value and impact of publicly reporting hospital performance measure data. DESIGN: Qualitative research. SETTING AND PARTICIPANTS: Administrators, physicians, nurses and other front-line staff from 29 randomly selected Joint Commission-accredited hospitals reporting core performance measure data. METHODS: Structured focus-group interviews were conducted to gather hospital staff perceptions of the perceived impact of publicly reporting performance measure data. RESULTS: Interviews revealed six common themes. Publicly reporting data: (i) led to increased involvement of leadership in performance improvement; (ii) created a sense of accountability to both internal and external customers; (iii) contributed to a heightened awareness of performance measure data throughout the hospital; (iv) influenced or re-focused organizational priorities; (v) raised concerns about data quality and (vi) led to questions about consumer understanding of performance reports. Few differences were noted in responses based on hospitals' performance on the measures. CONCLUSIONS: Public reporting of performance measure data appears to motivate and energize organizations to improve or maintain high levels of performance. Despite commonly cited concerns over the limitations, validity and interpretability of publicly reported data, the heightened awareness of the data intensified the focus on performance improvement activities. As the healthcare industry has moved toward greater transparency and accountability, healthcare professionals have responded by re-prioritizing hospital quality improvement efforts to address newly exposed gaps in care.

Atitude do Pessoal de Saúde , Hospitais/normas , Disseminação de Informação , Corpo Clínico Hospitalar/psicologia , Qualidade da Assistência à Saúde , Revelação , Grupos Focais , Humanos , Entrevistas como Assunto , Liderança , Motivação , Estados Unidos