Making Sense of Patient Safety Event Data

Over the past two decades, the focus on capturing and understanding patient safety events has led to the development of several initiatives and programs in hospitals across the country to increase the reporting of these events. Computerized reporting systems are an integral part of these programs. With these systems going live, hospitals now have databases that contain large numbers of patient safety event reports. Now, the challenge is to make sense of and effectively analyze the data by examining trends and predicting future events. The purpose of this practice-orientated paper is to describe and demonstrate how to apply advances in information visualization techniques and methods to patient safety event data with the goal of making these data more understandable and actionable. We will discuss the process of how we developed patient safety event visualizations for a multi-hospital healthcare system and provide visualization techniques, resources, guidelines, and practical examples.

[1]  Edward Tufte,et al.  Visual Explanations , 1997 .

[2]  L. Leape Reporting of adverse events. , 2002, The New England journal of medicine.

[3]  Colin Ware,et al.  Information Visualization: Perception for Design , 2000 .

[4]  Scott A. Shappell,et al.  A Human Error Approach to Accident Investigation: The Taxonomy of Unsafe Operations , 1997 .

[5]  Chandler Stolp,et al.  The Visual Display of Quantitative Information , 1983 .

[6]  J. Loeb,et al.  The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. , 2005, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[7]  Kathryn M McDonald,et al.  A national profile of patient safety in U.S. hospitals. , 2003, Health affairs.

[8]  Anne Elixhauser,et al.  How often are potential patient safety events present on admission? , 2008, Joint Commission journal on quality and patient safety.

[9]  Paul Strauss Human Factors In Engineering And Design , 2016 .

[10]  Ben Shneiderman,et al.  Analyzing Social Media Networks with NodeXL: Insights from a Connected World , 2010 .

[11]  Catherine Plaisant,et al.  The challenge of information visualization evaluation , 2004, AVI.

[12]  Scott A. Shappell,et al.  APPLYING REASON: THE HUMAN FACTORS ANALYSIS AND CLASSIFICATION SYSTEM (HFACS) , 2001 .

[13]  T. Brennan,et al.  INCIDENCE OF ADVERSE EVENTS AND NEGLIGENCE IN HOSPITALIZED PATIENTS , 2008 .

[14]  Harlan M. Krumholz,et al.  National trends in patient safety for four common conditions, 2005-2011. , 2014, The New England journal of medicine.

[15]  Anne Elixhauser,et al.  Patient safety events during pediatric hospitalizations. , 2003, Pediatrics.

[16]  William Wright,et al.  GeoTime Information Visualization , 2004, IEEE Symposium on Information Visualization.

[17]  C. Marano,et al.  To err is human. Building a safer health system , 2005 .

[18]  M. Holzman,et al.  National Analysis of Adverse Patient Safety Events in Bariatric Surgery , 2005, The American surgeon.

[19]  David S. Ebert,et al.  Visualization and computer graphics , 2007 .

[20]  P. Maurette [To err is human: building a safer health system]. , 2002, Annales francaises d'anesthesie et de reanimation.

[21]  Ivan Herman,et al.  Graph Visualization and Navigation in Information Visualization: A Survey , 2000, IEEE Trans. Vis. Comput. Graph..

[22]  S. Shappell,et al.  The Human Factors Analysis Classification System (HFACS) Applied to Health Care , 2014, American journal of medical quality : the official journal of the American College of Medical Quality.

[23]  John T. Stasko,et al.  Toward a Deeper Understanding of the Role of Interaction in Information Visualization , 2007, IEEE Transactions on Visualization and Computer Graphics.

[24]  Danah Boyd,et al.  Vizster: visualizing online social networks , 2005, IEEE Symposium on Information Visualization, 2005. INFOVIS 2005..

[25]  Ben Shneiderman,et al.  The eyes have it: a task by data type taxonomy for information visualizations , 1996, Proceedings 1996 IEEE Symposium on Visual Languages.

[26]  Edward R. Tufte,et al.  The Visual Display of Quantitative Information , 1986 .

[27]  J Gosbee,et al.  Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. , 2001, The Joint Commission journal on quality improvement.

[28]  Michael G Lenné,et al.  A systems approach to accident causation in mining: an application of the HFACS method. , 2012, Accident; analysis and prevention.

[29]  Chris North,et al.  Snap-together visualization: a user interface for coordinating visualizations via relational schemata , 2000, AVI '00.