A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care

Reports on errors can be a rich source for understanding their causes, cascades, and consequences, leading to interventions for improvement. There are national and international calls for the development of appropriate error reporting and taxonomy systems that are useful at the point of care. The current momentum and urgency for these developments present an opportunity to harness the benefits of computer visualization that helps structure and illustrate the “story” of an error. This visualization process could help overcome the shortcomings of current reporting methods and could aid in creating an unambiguous international error taxonomy. We present a concept for a visual error reporting interface. The ambulatory care domain is used for illustration. The system has the potential to provide a user friendly, efficient means of reporting errors. Errors reported in this way would populate a “visual database,” providing the ability to disseminate patient safety information in a straightforward, structured format that will be useful to a variety of stakeholders. Introduction A huge chasm exists between the potential and actual quality of care delivered by the health care industry. In the United States, this chasm appears to be consistently wide across the Nation and the spectrum of care delivery venues. Creation of a culture of safety is a critical first step for health care organizations that wish to improve quality and safety. One of the steps in developing a culture of safety is the recognition by staff and clinicians of errors that occur on a regular basis. One of the primary drivers to achieve this recognition is error reporting. Reporting systems need to be safe (i.e., free from blame), easy, and worthwhile. 5 Error reports can be a rich source for uncovering errors, and through further study, can lead to an understanding of causes, cascades, and consequences of errors, in turn leading to the design of interventions for improvement. Error reports represent the “tip of the iceberg,” as only a small fraction of errors are typically reported, and the information contained in the reports is limited to what reporters perceive and are willing to share. Other methods of analysis, which may be based on error reports, include failure modes and effects analysis, root cause analysis, chart review, and direct observation. These are needed to provide a more complete assessment of risks within an organization. Error