Application of information technology: Integrating Incident Reporting into an Electronic Patient Record System

Developments in information technology offer new opportunities to design electronic patient record systems (EPR) which integrate a broad range of functions such as clinical decision support, order entry, or electronic alerts. It has been recently suggested that EPR could support new applications for disease surveillance and patient safety. We describe the integration of a voluntary incident reporting system into an EPR used in operating theatres, to allow the reporting of accidents and preventable complications. We assessed system's reliability and users' acceptance. During the 4-years observation period (2002-2006), 48,983 interventional procedures were performed. Clinicians documented 85.1% of procedures on the incident reporting form. Agreement between chart review and electronically reported incidents was 80.6%. The integration of an incident reporting system into an EPR is reliable and well supported by health care professionals.

[1]  C Safran,et al.  Guidelines for management of HIV infection with computer-based patient's record , 1995, The Lancet.

[2]  Stuart R. Lipsitz,et al.  Erratum: The reliability of medical record review for estimating adverse event rates (Annals of Internal Medicine (2002) 136 (812-816)) , 2002 .

[3]  Stuart Lipsitz,et al.  The Reliability of Medical Record Review for Estimating Adverse Event Rates , 2002, Annals of Internal Medicine.

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

[5]  Richard N. Shiffman,et al.  Review: Computer-based Guideline Implementation Systems: A Systematic Review of Functionality and Effectiveness , 1999, J. Am. Medical Informatics Assoc..

[6]  J M Teich,et al.  Computerized physician order entry and quality of care. , 1994, Quality management in health care.

[7]  Elizabeth H Bradley,et al.  The gap between nurses and residents in a community hospital's error-reporting system. , 2005, Joint Commission journal on quality and patient safety.

[8]  D J Spiegelhalter,et al.  How does computer-aided diagnosis improve the management of acute abdominal pain? , 1992, Annals of the Royal College of Surgeons of England.

[9]  Ben Shneiderman,et al.  Designing the User Interface: Strategies for Effective Human-Computer Interaction , 1998 .

[10]  Marilyn D Paterno,et al.  Electronic alerts to prevent venous thromboembolism among hospitalized patients. , 2005, The New England journal of medicine.

[11]  R F Beckley,et al.  Clinical computing in a teaching hospital. , 1985, The New England journal of medicine.

[12]  K. Sanborn,et al.  Detection of Intraoperative Incidents by Electronic Scanning of Computerized Anesthesia Records: Comparison with Voluntary Reporting , 1996, Anesthesiology.

[13]  R. Goldman,et al.  The reliability of peer assessments of quality of care. , 1992, JAMA.

[14]  W J Russell,et al.  The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. , 1993, Anaesthesia and intensive care.

[15]  Axel Junger,et al.  Using an Anesthesia Information Management System to Prove a Deficit in Voluntary Reporting of Adverse Events in a Quality Assurance Program , 2004, Journal of Clinical Monitoring and Computing.

[16]  Ben Shneiderman,et al.  Designing the User Interface: Strategies for Effective Human-Computer Interaction (4th Edition) , 2004 .

[17]  Clifford Goodman,et al.  American Society of Anesthesiologists , 2020, Definitions.

[18]  R. Lagasse,et al.  Factors Influencing the Reporting of Adverse Perioperative Outcomes to a Quality Management Program , 2000, Anesthesia and analgesia.

[19]  Beth Dawson,et al.  Basic & Clinical Biostatistics , 1990 .

[20]  Richard N. Shiffman,et al.  The Incorporation of Clinical Practice Guidelines for Glaucoma into an Ophthalmology Electronic Medical Record , 2005, AMIA.

[21]  S D Small,et al.  The incident reporting system does not detect adverse drug events: a problem for quality improvement. , 1995, The Joint Commission journal on quality improvement.

[22]  J. Fox,et al.  Evaluation of computer support for prescribing (CAPSULE) using simulated cases , 1997, BMJ.

[23]  P. Barach,et al.  Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems , 2000, BMJ : British Medical Journal.

[24]  P. Myles,et al.  Analysis of demographic characteristics. , 1994, Anaesthesia and intensive care.

[25]  Paul C. Tang,et al.  Position Paper: AMIA Advocates National Health Information System in Fight Against National Health Threats , 2002, J. Am. Medical Informatics Assoc..

[26]  T. Brennan,et al.  Incidence of adverse events and negligence in hospitalized patients. , 1991, The New England journal of medicine.

[27]  E. Hing,et al.  Use of computerized clinical support systems in medical settings: United States, 2001-03. , 2005, Advance data.

[28]  Rd Dripps,et al.  New classification of physical status , 1963 .

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

[30]  Astrid M. van Ginneken,et al.  The computerized patient record: balancing effort and benefit , 2002, Int. J. Medical Informatics.

[31]  D. Christakis,et al.  Use of Incident Reports by Physicians and Nurses to Document Medical Errors in Pediatric Patients , 2004, Pediatrics.

[32]  Angelia Mosley-Williams,et al.  Computer applications in clinical practice , 2005, Current opinion in rheumatology.

[33]  T. Brennan,et al.  Identifying Adverse Events Caused by Medical Care: Degree of Physician Agreement in a Retrospective Chart Review , 1996, Annals of Internal Medicine.

[34]  N. Stanhope,et al.  An evaluation of adverse incident reporting. , 1999, Journal of evaluation in clinical practice.