2008 Faculty Researchers

Yang Gong, MD, PhD

Analyzing Human Factors in Medical Error Events

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Department

Management and Informatics

Office Location

Clark 303

Phone #:

Office: (573) 882-5772
Fax: (573) 882-6158

Summary

Medical error is a major contributor to avoidable deaths in the inpatient care setting. As a result, the study and reduction of medical errors have become a major concern in healthcare today. One way to learn from errors is to establish an effective medical error reporting system in which voluntary reporting systems are an indispensable component. Increasing usability of the voluntary reporting systems through the use of human factor analysis is proposed as one approach.

Employing human-centered approach and ontological engineering method, we propose to design an intelligent medical error reporting system (IMER) based on the analyses of an existing Patient Safety Network (PSN) system, to build an ontology and human-centered reporting interfaces which are the core of the intelligent reporting system, facilitating data collection, storage and further analysis at regional and national levels.

During this small grant support, the fund will be used for content analysis and semantic analysis of one year PSN reports and prototyping an interface representing the relationships between harm scores, incident categories, and free text descriptions in the system. To be specific,

References:

Fischer, M. A., K. M. Mazor, et al. (2006). Learning from Mistakes. Factors that Influence How Students and Residents Learn from Medical Errors. 21: 419-423.

Gong, Y., M. Zhu, et al. (2007). Clinical communication ontology for medical errors. Medinfo 2007. Austrialia.

Kohn, L. T., J. M. Corrigan, et al. (1999). To err is human. Washington, DC, National Academy Press.

Longo, D. R., J. E. Hewett, et al. (2005). The Long Road to Patient Safety: A Status Report on Patient Safety Systems. 294: 2858-2865.

Zhan, C., E. Kelley, et al. (2005). "Assessing patient safety in the United States: challenges and opportunities." Medical Care 43(3): I-42-I-47.

Zhang, J., V. L. Patel, et al. (2004). "A cognitive taxonomy of medical errors." Journal of Biomedical Informatics 37(3): 193-204.