Cataloging Errors From Reported Informatics Patient Safety Adverse Events

Abstract

An effective feedback mechanism to enable Health Information Technology (HIT) users and other stakeholders to report adverse events that occur after system deployment is an essential line of defense against risks to patient safety (Billings, 1999). The goal of the Patient Safety Informatics-Cognitive Analysis Model (PSI-CAM) project is to develop a practical theory-based framework to aid adverse event analysis and to apply it to patient safety issues reported to the Informatics Patient Safety (IPS) Office of the Veterans Health Administration (VHA), Department of Veterans Affairs (VA). This framework is based on a user-centered model of human interaction with technologies (Norman, 1986) and as such it helps ensure the analysis includes consideration of the relationship between the user-technology interface and the adverse events reported. Here we describe the framework and illustrate its use with real-world examples of issues reported to the VHA IPS Office.