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A root cause analysis interface for error reporting

Published: 01 June 2007 Publication History

Abstract

We describe a web-based interface that facilitates entering and analyzing medical errors. It uses an interactive causal tree-building component. The interactive component allows a user to build a causal tree with any number of events and antecedents. This replaces a form-based approach that is limited to a predetermined number of events and antecedents. After the causal tree is completed, the user can save the tree to a database. Causal trees can be retrieved and rebuilt as well. We developed an algorithm that, given a data bank of reported errors, will help detect similar events. This facilitates recognizing patterns of errors.

References

[1]
Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. NEJM 1991; 324:370--376.
[2]
Institute of Medicine (IOM). To Err Is Human: Building a Safer Health System. National Academies Press, Washington, D.C. 2000.
[3]
Starfield, B. (2000, July 26). Is US health really the best in the world? Journal of the American Medical Association, 284(4), 483--485.
[4]
Barker K. N., Flynn E. A., Pepper G. A., et al. Medication errors observed in 36 healthcare facilities. Archives of Internal Medicine. 2002; 162:1897--1903.
[5]
Kaplan HS, Callum JL, Rabin-Fastman B, Merkley LL. The Medical Event Reporting System for Transfusion Medicine: will it help get the right blood to the right patient? Transfusion Medicine Review 2002; 16(2):86--102.
[6]
Mekhjian HS, Bentley TD, Ahmad A, Marsh G. Development of a web-based event reporting system in an academic environment. J Am Med Informat Assoc. 2004; 11(1):11--18.
[7]
Pace WD, Staton EW, Higgins GS, et al. Database design to ensure anonymous study of medical errors: a report from the ASIPS Collaborative. J Am Med Inform Assoc 2003 Nov-Dec; 10(6):531--40.

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  1. A root cause analysis interface for error reporting

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    Published In

    cover image ACM SIGCSE Bulletin
    ACM SIGCSE Bulletin  Volume 39, Issue 2
    June 2007
    158 pages
    ISSN:0097-8418
    DOI:10.1145/1272848
    Issue’s Table of Contents

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    Association for Computing Machinery

    New York, NY, United States

    Publication History

    Published: 01 June 2007
    Published in SIGCSE Volume 39, Issue 2

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    Author Tags

    1. causal tree
    2. medical errors
    3. root cause analysis

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